Provider Variables in Medicare Fee-for-Service and Encounter Data

Purpose

There are many different provider variables in the Medicare Fee-for-Service (FFS) Claims and Encounter data. Researchers are often interested in the performing NPI and/or the facility CCN or organizational NPI, but other variables are sometimes useful. The purpose of this article is to help you understand these variables and we present the completeness of these data to assist researchers who are designing research studies using Medicare FFS claims and Encounter data.

Current Version Date:
01/10/2024
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Medicare Fee-for-Service Data

Table 1 includes an overview of some of the provider variables that are available in the CMS data. These are variables that are most commonly asked about at ResDAC. Please note that many variables include the word “physician” in their name, but the variable itself can contain other individual medical professionals including nurses or nurse practitioners.

You can learn more about provider variables by reviewing the CMS Claims Processing Manual, specifically the chapters on completing the CMS-1450 and CMS-1500 forms.

Table 1. Most Asked Provider Definitions
Term Definition
Provider CMS will use the term “provider” to indicate a doctor, hospital, health care professional, or health care facility.
CMS Certification Number (CCN) A CMS certification number provided to facilities and suppliers who request to be accredited by CMS
Organization/Group A practice consisting of more than one clinician
Attending Physician This is the clinician that is responsible for the beneficiary’s medical treatment and care. This variable is required for all claims, except for nonscheduled transportation service claims.
Operating Physician This is the clinician that performed the surgical procedure listed on the claim. This variable is required when a surgical procedure is present.
Other Physician This variable is required in very specific situations. It is related to the corresponding qualifier category. Please refer to CMS’s Claims Processing Manual for detailed information on the qualifier codes.
Rendering Physician This is the clinician who provided the medical service or non-surgical procedure. This variable is required when a hospital is required by state or federal law to submit separate facility and professional claims for the same service.
Referring Physician This is the clinician who sends a beneficiary to another provider for service. This variable is required when the referring clinician is different from the attending clinician. For Carrier claims, this is the clinician who referred to the beneficiary to the clinician who ordered the services.
Performing Physician This variable describes the clinician/supplier who performed the service on the Carrier line item. The claims processing manual has no specific rules about when this variable is required.
Provider Variable Completeness

Tables 2 and 3 provide a general overview of provider variable availability and completeness by file. These tables were created using Version K of the CMS claims data. Unique Physician Identification Numbers (UPINs) and Provider Identification Numbers (PINs) were not calculated for completeness as they were phased out starting in 2007.

Some provider variables may be filled less than 100% of the time. This is not indicative of data quality. There are circumstances where a partial fill is justified. For example, the operating NPI should only be filled when there is a surgical procedure on the claim, and we don’t expect all claims to have a surgical procedure.

Table 2. NPI Completeness in RIF Medicare FFS Claims Data (Base Claim File), Version K
Variable Name IP OP SNF HHA Hospice Carrier DME MedPAR
Provider Number* 100% 100% 100% 100% 100%
Organization (or group) NPI Number 99.9% 100% 99.9% 100% 100%
Claim Attending Physician NPI Number (FFS) 99.9% 99.9% 100% 99.9% 99.7%
Claim Operating Physician NPI Number (FFS) 57.9% 17.6% 0.9% 0.9% 4.4%
Claim Other Physician NPI Number (FFS) 6.0% 2.1% 3.1% 0.2% 3.2%
Claim Rendering Physician NPI 1.7% 0.7% 0.1% 0.2% 1.3%
Claim Referring Physician NPI Number 3.2% 4.10% 49.9%
Claim Service Location NPI Number 10.4% 3.20% 20.6%
Carrier Claim Referring Provider ID Number (NPI) 80.8%
Carrier/DMERC Claim Referring Physician UPIN Number x
Care Plan Oversight (CPO) Provider Number 0%
Carrier Claim Billing NPI Number 99.9%
Carrier Claim Site of Service NPI Number 27.4%
Carrier/DMERC Claim Ordering Physician NPI Number 99.9%
MedPAR Organization NPI Number 100%
MEDPAR Provider Number** 100%
* This Provider Number is the same as the CCN.
** The MedPAR Provider number is derived from the CCN. In the MedPAR, if the CCN has an alpha character in the 3rd position, then it is replaced with either a 0 or 1.
Table 3. NPI Completeness in RIF Medicare FFS Claims Data (Revenue Center and Line Item Files), Version K
Encounter Data

Encounter Data have similar provider variables when compared to Medicare FFS data. However, one major difference is that the CCN is not included. NPI variables are the only provider identifiers; tax number is also included.

Tables 4 and 5 provide a general overview of provider variable availability and completeness by file. These tables were created using 2016-2020 Encounter Data with chart reviews removed.

Some provider variables may be filled less than 100% of the time. This is not indicative of data quality. There are circumstances where a partial fill is justified. The FAQ about MAOs Encounter Data Submission and Processing and Encounter Data Submission Guide can be used to better understand circumstances when an NPI value should be filled.

Table 4. NPI Completeness in RIF Encounter Records (Base Claim File), 2016-2020 Average
Variable Name IP SNF HHA OP Carrier DME
Provider Number* Not reported in Encounter Not reported in Encounter Not reported in Encounter Not reported in Encounter Not reported in Encounter Not reported in Encounter
Organizational NPI 100% 100% 100% 100% 100% 100%
Rendering NPI 4.0% 3.1% 5.8% 4.1% 67.6% 5.1%
Attending NPI 85.5% 85.1% 80.7% 85.7%
Operating NPI 40.8% 0.8% 0.5% 13.2%
Other NPI 4.8% 0.0% 0.0% 0.3%
Tax Number 100% 99.9% 99.9% 99.9% 99.9% 99.9%
Referring NPI 1.2% 0.9% 29.1% 31.7%
* The Provider Number is the same as the CCN.
Table 5. NPI Completeness in RIF Encounter Records (Line Item Files), 2016-2020 Average
Variable Name IP SNF HHA OP Carrier DME
Rendering NPI 0.86% 5.14%
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Article Information

Author:
Samantha Saykao
Level:
Introduction
Topic:
Analytic Guidance, Data Files or Variables
Program:
Medicare
Category:
Medicare Encounter, Medicare Fee-For-Service Claims
Disclaimer:
The process and materials mentioned as part of this KnowledgeBase article are current, as of the publication date on the article, to the best of our knowledge. The examples provided are correct in the aggregate but may not apply to every subgroup or circumstance that a researcher may wish to study. It is up to the researcher to conduct analysis and confirm that the patterns described in this KnowledgeBase article apply to his/her particular study. If your research findings appear to contradict the advice provided, please contact ResDAC at resdac@umn.edu.