Provider Variables in Medicare Fee-for-Service Data

Purpose

  • Availability of provider variables
  • Provider variable completeness
  • Provider variable definitions
Current Version Date:
09/30/2021

There are many different provider variables in the Medicare Fee-for-Service (FFS) Claims 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 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.

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.

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.

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.