Using the Carrier File (FORMERLY CALLED THE PHYSICIAN/SUPPLIER PART - - PowerPoint PPT Presentation

Using the Carrier File

(FORMERLY CALLED THE PHYSICIAN/SUPPLIER PART B FILE)

Marshall McBean, M.D., M.Sc. Director of ResDAC University of Minnesota

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Capturing information on the CMS 1500

The important groups of Carrier File variables from the CMS 1500 form

• Claim “Header” or “Fixed Portion” variables. The

“header” portion of CMS 1500 form, including the

• diagnoses. Called “Base Claim File” portion in

CCW/Buccaneer record layout.

• Note: The patient characteristics (demographics) which

were only in the CCW Beneficiary Summary File are now in the CCW claims files, too.

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The important groups of Carrier File variables from the CMS 1500 form

• Line Item variables. Those variables found in the

“Trailer” portion of the CMS 1500 form. Called “Line File” portion in CCW/Buccaneer record layout.

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Carrier File Data Dictionaries

• CCW data dictionary:

http://www.ccwdata.org/data- dictionaries/index.htm

• Classic CMS Carrier file data dictionary:

http://www.resdac.org/cms-data/files/carrier- rif/data-documentation

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Useful variables in the Base Claim File portion of the Carrier File

• Information about the beneficiary
• BENE_ID (Encrypted)
• Beneficiary demographics

» Date of birth » Gender » Race/ethnicity

• Beneficiary place of residence

» State, county and zip code

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Useful variables in the Line File portion of the Carrier File

• Information about the claim
• Claim From Date
• Claim Through Date
• Claim Payment Amount
• Claim Diagnosis Codes

» occurs up to 8 times (starting with 2007 data) » uses ICD-9-CM codes – ICD-10 is coming October 2014 » diagnosis of XX000 = a laboratory test

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Carrier File Diagnoses

• “By rule”, there should be no “rule-outs”
• Diagnoses that are found in the line items are

truly also in the claim file portion of the record

• Determination of co-morbidities is an issue as

discussed by Beth in her presentation of MedPAR file

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Useful variables in the Line File portion of the Carrier File

• Note: a line item or Line File portion may occur up

to 13 times on one claim

• No longer a “count variable”
• Line Diagnosis Code
• It can be any of the up to 8 possible diagnoses in the

claim file portion of the Carrier File

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Useful variables in the Line File portion of the Carrier File

• 3 variables useful for linking Carrier claims to

MedPAR hospital or to outpatient claims

• 1. Line Place of Service Code

2 and 3. Dates of service (Line First Expense Date and Line Last Expense Date)

Reasons to link the claims:

• 1. to sum the amount reimbursed for care,
• 2. to “validate” the occurrence of a procedure
• 3. to avoid duplicate counting of cases or

procedures

• 4. Others?

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Examples of line place of service codes

11 = Office 12 = Home 21 = Inpatient hospital 22 = Outpatient hospital 23 = Emergency room - hospital 24 = Ambulatory surgical center 31 = Skilled nursing facility

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Additional examples of line place of service codes

32 = Nursing facility 33 = Custodial care facility 34 = Hospice 35 = Adult living care facilities (ALCF) (eff. NYD – added 12/3/97) 41 = Ambulance - land 42 = Ambulance - air or water 50 = Federally qualified health centers (eff. 10/1/93)

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More useful variables in the Line File portion of the Carrier File

• Line Healthcare Common Procedure Coding

System (HCPCS) Code

• Line HCPCS Initial Modifier Code
• Line HCPCS Second Modifier Code
• Line HCPCS Third Modifier Code
• Line HCPCS Fourth Modifier Code

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HCPCS: Healthcare Common Procedure Coding System Codes

• Level 1 - 5 position numeric codes -- are CPT (Current

Procedural Terminology) Codes of American Medical Association

• e.g., 99201 Office or other outpatient visit for the

evaluation and management of new patient

• Level 2 - 5 position alpha-numeric codes
• e.g., J0540 Injection, penicillin G benzathine and

penicillin G procaine, up to 1,200,000 units

• Level 3 - 5 position alpha-numeric codes beginning with W,

X, Y or Z

• Note: XX000 as a diagnosis = a laboratory service

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Examples of Level 1 HCPCS or CPT codes

• 00100 -01999 Anesthesia
• 10040 - 69990 Surgery
• 70010 - 79999 Radiology
• 80049 - 89399 Pathology and Laboratory
• 90281 - 99199 Medicine
• 99201 - 99499 Evaluation and Management

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HCPCS – Issues for researchers (1)

• 1. What is actually included in a Evaluation and

Management (E&M) visit? Codes 99201 - 99499

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HCPCS - Examples of level 2 codes

• A0000 - A0999 Transportation Services including

Ambulance

• A4000 - A8999 Medical and Surgical Supplies
• A9000 - A9999 Administrative, Miscellaneous and

Investigational

• B4000 - B9999 Enteral and parenteral therapy

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HCPCS - More examples of level 2

• A4253 - Blood Glucose or reagent strips for home

blood glucose monitoring- per 50

• A4259 - Lancets -box of 100
• A2000 - Manipulation of spine by chiropractor
• A0344 - Ambulance services, ALS, non-

emergency, no specialized ALS

• plus ---- lots of other ambulance

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HCPCS - examples of level 1 & level 2 preventive services codes

• Preventive services
• Influenza vaccine

90654, 90656 or 90658*

• Influenza vaccine administration

G0008

• Pneumococcal polysac. vaccine

90732

• Pneumococcal vaccine administration

G0009

• Fecal occult blood test

G0238 or G0107

• Flexible sigmoidoscopy

G0104

• Colonoscopy

G0105 * Note: In 2011, discontinue 90656 and use Q2035 – Q2039 for split-virus vaccine….. pay attention. Things keep changing .

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Changes in HCPCS

• Level 1 and Level 2 HCPCS may change annually
• Level 3 HCPCS may change more frequently
• CMS is making an effort to eliminate Level 3

HCPCS

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HCPCS - Level 3 codes

• Repeat definition : 5 position alpha-numeric codes

beginning with W, X, Y or Z

• Source = the MACs (Medicare Administrative

Contractors

• CMS is really planning to eliminate

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HCPCS Modifiers

• 2 Position codes
• Level 1 - numeric
• e.g., 21 - Prolonged Evaluation and Management

Services

• 26 - Professional Component
• Level 2 - alpha or alpha-numeric
• TC - Technical Component
• LT = left, RT = right

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HCPCS Modifiers

• Level 3 – formerly from Carriers, now from MACs
• HCPCS modifiers may also change in the course of

a study, but much less likely

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More useful variables in the Line File portion of the Carrier File

• Approximately 10,000 HCPCS codes
• What’s a poor researcher to do?
• HCPCS Line NCH BETOS Code
• Useful for Aggregating

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BETOS codes – line NCH BETOS code

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 - opthamology M5D = Specialist - other M6 = Consultations P0 = Anesthesia

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Physician services and amount Medicare paid for them by, BETOS code

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BETOS Code Services Amount Paid M1A = Office visits - new 12,063,567 $729,435,905 M1B = Office visits - estab 175,981,446 $5,854,022,879 M2A = Hospital visit - initial 9,084,444 $915,516,580 M2B = Hospital visit - subs 82,434,957 $3,572,740,464 M2C = Hospital visit - critical care 2,616,542 $302,633,080 M3 = Emergency room visit 15,135,564 $1,061,258,401 M4A = Home visit 1,531,304 $97,078,383 M4B = Nursing home visit 19,766,584 $720,985,090 M5A = Specialist - pathology 16,926,656 $673,411,742 M5B = Specialist - psychiatry 17,229,471 $654,250,877 M5C = Specialist - opthamology 21,782,022 $1,007,691,689 M5D = Specialist - other 9,641,201 $127,907,388

More useful variables in the Line File portion of the Carrier File

• Line Allowed Charge Amount - the charges allowed

by CMS

• Line NCH Payment Amount - the amount paid by

CMS

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Relationship between line allowed charge amount and line NCH payment amount

• NCH Payment Amount generally 80% of Line NCH

Allowed Charge Amount. WHY?

• For laboratory services the two values are the
• same. WHY?

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More useful variables in the Line File portion of the Carrier File

• Don’t over count the count.
• Carrier Line Miles/Time/Units/Services (MTUS) count
• Carrier Line Miles/Time/Units/Services indicator code
• Did the beneficiary use 40 ambulances?

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MTUS Indicator Code Values

0 = Values reported as zero (no allowed activities) 1 = Transportation (ambulance) miles 2 = Anesthesia time units 3 = Services 4 = Oxygen units 5 = Units of blood

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More useful variables in the Line File portion of the Carrier File

• Information about the provider of service:
• Carrier Line Performing PIN Number
• Carrier Line Performing UPIN Number
• Line CMS Provider Specialty Code
• Carrier Line Performing NPI (National Provider

Identification Number)

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Provider of service information

• The provider had to submit a PIN (Provider

Identification Number) on the CMS 1500 claim

• The Carrier picked a UPIN (Unique Physician

Identification Number) for that PIN

• CMS added the Provider Specialty based on the

UPIN

PIN, UPIN, AND PROVIDER SPECIALTY – THE OLD STORY

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National Provider Identification Number – NPI - and its implementation

• In 2006 CMS started requiring the use NPI for

providers in in billing using the CMS 1500 form

• Electronic submission of claims
• Through 1/2/ 06 – NPI not accepted
• 2/3/06 – 10/1/06 – NPI accepted, but only if UPIN is

also reported

• 10/2/06 – 5/22/07 – NPI or UPIN accepted;

encourage both to speed payment

• 5/23/07 and after – NPI must be submitted; No UPIN
• Paper submission of claims
• All of 2006 NPI not accepted; no place on claim

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NPI and UPIN use in 2006

Per ercen ent t of Phys ysici ician-re rela lated ed Carrie ier r Lin ine I e Item ems s wit ith NPI PI an and/ d/or UP UPIN in in 2006 006 All of 2006 006 After er October

• ber 1st

NPI only 0.02 02 0.05 05 UP UPIN onl nly 97.05 05 92.72 .72 Both 1.65 1.65 5.53 53 Nei either er 1.28 1.28 1.8 1.81

MINIMAL IMPACT OF NPI

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Percent of physician-related Carrier line items with NPI and/or UPIN July through Dec., 2007

Neither 0.42 UPIN only 12.35 NPI only 5.30 Both NPI and UPIN 81.93

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NPI implementation – Summary of the new story

• Minimal impact on the 2006 data files, but major

conversion by second half of 2007. Still need to work with UPINs for those 2 years.

• 2008 and 2009 only have NPI.
• Use the TAX_NUM variable which has replaced the

PIN to identify the entity that is paid for the Part B service.

• Specialty code now derived by CMS from NPI.

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Line CMS Provider Specialty Codes

01 = General practice 02 = General surgery 03 = Allergy/immunology 04 = Otolaryngology 05 = Anesthesiology 06 = Cardiology 07 = Dermatology 08 = Family practice 09 = Gynecology (osteopaths only)(discontinued 5/92 use code 16) 10 = Gastroenterology 11 = Internal medicine

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More line CMS provider specialty codes

40 = Hand surgery 41 = Optometry (revised 10/93 to mean optometrist) 42 = Certified nurse midwife (eff 1/87) 43 = CRNA, anesthesia assistant (eff 1/87) 44 = Infectious disease 45 = Mammography screening center 46 = Endocrinology (eff 5/92) 47 = Independent Diagnostic Testing Facility (IDTF) (eff. 6/98) 48 = Podiatry

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Examples of uses of the Carrier File

• Counting services provided by physicians and
• thers
• Identifying cohorts of persons with chronic

diseases (Next presentation)

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Counting services provided by physicians and other Part B providers

• Example: Mammography
• How many women received a mammogram in 200X?

Example is pre-2007.

• How do you define mammography – all??; DX??;

screening?? What HCPCS codes do you use?

• Why use the Carrier file?
• Would you need to use additional files? Any additional

codes?

• Do you want to count mammograms, or women

tested?

• What are you worried about in getting an accurate

count?

• Too few???, or Too many???

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Mammography HCPCS pre-2007

• Mammography - unilateral

76090

• Mammography - bilateral

76091

• Mammography - screening

76092

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Claims for Mammogram, by Type of Mammogram, Female Medicare Beneficiaries, 1999-2001

(RESIDENTS OF SEER AREAS WITHOUT BREAST CANCER)

Type of Type of Mammogram Carrier File Outpatient Carrier + Carrier or Overcount Undercount File Outpatient Outpatient using both Carrier only Unilateral - Dx 2,279 1,388 3,667 2,474 1,388 Bilateral - Dx 6,578 3,282 9,860 7,444 3,282 Screening 18,237 10,204 28,441 19,190 10,204 Total claims 27,094 14,874 41,968 29,108 14,874 Total persons 25,359 13,994 39,353 26,112 13,241 753 Source of Data Number of Claims(Black) or Persons (Red)

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Claims for Mammogram, Female Medicare Beneficiaries, 1999-2001

(Residents of SEER Areas without breast cancer)

Type of Mammogram Carrier File Outpatient Carrier + Carrier or Overcount Undercount File Outpatient Outpatient using both Carrier only Unilateral - Dx Bilateral - Dx Screening Total claims 27,094 14,874 41,968 29,108 14,874 Total persons 25,359 13,994 39,353 26,112 13,241 753 Number of Claims or Persons

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Claims for Mammogram, female Medicare beneficiaries, 1999-2001

(Residents of SEER areas without cancer)

Type of Mammogram Overcount % Overcount Undercount % of Total if counting both Carrier only used Carrier only Unilateral - Dx Bilateral - Dx Screening Total claims 14,874 0.35 Total persons 13,241 50.7 753 0.97

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Using 5% or 100% Carrier File

• 5% sample verses 100%
• You cannot receive 100% national Carrier File
• But you may need the 100% Carrier File to have

enough power to study smaller geographic areas

• May have 100% selected by demographics,

diagnoses, procedures, etc. Barb will talk about tomorrow.

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