The code used to identify if there was a deviation from the standard method of calculating payment amount.
This field is populated for those claims that are required to process through the Outpatient PPS PRICER software. The type of bills (TOB) required to process through are: 12X,13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code '07' and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.
Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.
It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.
VALUES D, U & T REPRESENT THE FOLLOWING:
D = Discounting fraction (currently 0.5)
U = Number of units
T = Terminated procedure discount (currently 0.5)
|A||A valid HCPCS code not subject to a fee schedule payment. Reimbursement is
calculated on provider submitted charges.
|B||A valid HCPCS code subject to the fee schedule payment. for the provider billed
charges. NOTE: There is an exception for Critical Access Hospitals (provider
numbers XX1300-XX1399) with reimbursement method 'J' (all-inclusive method)
and dates of service on or after 7/1/01. In these situations, reimbursement for
professional services (revenue codes 96X, 97X, 98X) is always at the fee schedule
amount of logic is not applicable.
|C||Unlisted Rehabilitation Carrier Priced HCPCS|
|D||A valid radiology HCPCS code subject to the Radiology Pricer and the rate is
reflected as zeroes on the HCPCS file and cost report. The Radiology Pricer treats
this HCPCS as a non-covered service. Reimbursement is calculated on provider
|E||A valid ASC HCPCS code subject to the ASC Pricer. The rate is reflected as zeroes on
the HCPCS file. The ASC Pricer determines the ASC payment rate and is reported
on the cost report.
|F||A valid ESRD HCPCS code subject to the parameter rate. Reimbursement is the
lesser of provider submitted charges or the fee schedule amount for non-dialysis
HCPCS. Reimbursement is calculated on the provider file rates for dialysis HCPCS.
NOTE: The ESRD Pricing Indicator is used when processing the ESRD claim. The nonESRD pricing indicator is used only for Inpatient claims as follows: valid Hemophilia
HCPCS for inpatient claim only and code is summed to parameter rate.
|G||= A valid HCPCS, code is subject to a fee schedule, but the rate is no longer present
on the HCPCS file. Reimbursement is calculated on provider submitted charges.
|H||A valid DME HCPCS, code is subject to a fee schedule. The rates are reflected
under the DME segment. Reimbursement is calculated either on a fee schedule, provider submitted charges or the lesser of provider submitted, or the fee schedule
depending on the category of DME.
|I||A valid DME category 5 HCPCS, HCPCS is not found on the DME history record, but a
match was found on HIC, category and generic code. Claim must be reviewed by
Medical Review before payment can be calculated.
|J||A valid DME HCPCS, no DME history is present, and a prescription is required before
delivery. Claim must be reviewed by Medical Review.
|K||A valid DME HCPCS, prescribed has been reviewed, and fee schedule payment is
approved as prescription was present before delivery.
|L||A valid TENS HCPCS, rental period is six months or greater and must be reviewed by
Medical Review. This code will be automatically set by the system.
|M||A valid TENS HCPCS, Medical Review has approved the rental charge in excess of
five months. This must be set by Medical Review. This must be set by Medical
Review when approved for payment.
|N||Paid based on the fee amount for non ESRD TOB's. NOTE: Fee amount is paid
regardless of charges.
|R||A valid radiology HCPCS code and is subject to APC. The rate is reported on the
cost report. Reimbursement is calculated on provider submitted charges.
|S||Valid influenza/PPV HCPCS. A fee amount is not applicable. The amount payable is
present in the covered charge field. This amount is not subject to the coinsurance
and deductible. This charge is subject to the provider's reimbursement rate.
|T||Valid HCPCS. A fee amount is present. The amount payable should be the lower of
the billed charge or fee amount. The system should compute the fee amount by
multiplying the covered units times the rate. The fee amount is not subject to
coinsurance and deductible or provider's reimbursement rate.
|U||= Valid ambulance HCPCS. A fee amount is present. The amount payable is a
blended amount based on a percentage of the fee schedule and a percentage of
the reasonable cost. The fee amount is subject to coinsurance and deductible.
|X||Unclassified drug as subject to manual pricing.|