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

Capturing information on the CMS 1500 2

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. 3

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. 4

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 5

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 6

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 7

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 8

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 9

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? 10

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 11

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) 12

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 13

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 14

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 15

HCPCS – Issues for researchers (1) 1. What is actually included in a Evaluation and Management (E&M) visit? Codes 99201 - 99499 16

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 17

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 18

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 . 19

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 20

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 21

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 23

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 24

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 25

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 26

Physician services and amount Medicare paid for them by, BETOS code BETOS Code Services Amount Paid 12,063,567 $729,435,905 M1A = Office visits - new 175,981,446 $5,854,022,879 M1B = Office visits - estab 9,084,444 $915,516,580 M2A = Hospital visit - initial 82,434,957 $3,572,740,464 M2B = Hospital visit - subs 2,616,542 $302,633,080 M2C = Hospital visit - critical care 15,135,564 $1,061,258,401 M3 = Emergency room visit 1,531,304 $97,078,383 M4A = Home visit 19,766,584 $720,985,090 M4B = Nursing home visit 16,926,656 $673,411,742 M5A = Specialist - pathology 17,229,471 $654,250,877 M5B = Specialist - psychiatry 21,782,022 $1,007,691,689 M5C = Specialist - opthamology 9,641,201 $127,907,388 M5D = Specialist - other 27

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 28

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? 29

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? 30

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 31

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) 32

Provider of service information PIN, UPIN, AND PROVIDER SPECIALTY – THE OLD STORY  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 33