The meaning of the values varies by type of bill (TOB) ****Inpatient Hospital Pricer Return Codes****** ******************TOB 11X*********************** Inpatient Hospital Payment return codes: 00 = Paid normal DRG payment 01 = Paid as a day outlier (NOTE: day outlier no longer being paid as of 10/1/97) 02 = Paid as a cost outlier 03 = Transfer paid on a per diem basis up to and including the full DRG 05 = Transfer paid on a per diem basis up to and including the full DRG which also qualified for a cost outlier payment 06 = Provider refused cost outlier 10 = DRG is 209, 210, or 211 and post- acute transfer 12 = Post-acute transfer with specific DRGs. The following DRG's: 14, 113, 236, 263, 264, 429, 483 14 = Paid normal DRG payment with per diem days = or > GM ALOS 16 = Paid as a cost outlier with per diem days = or > GM ALOS 33 = For inpatient PPS, it means paid a per diem payment to the transferring IPPS hospital (when the patient transfers to an IPPS hospital) up to and including the full DRG payment if the covered days are less than the geometric Inpatient Hospital Error return codes: 51 = No provider specific information found 52 = Invalid MSA# in provider file 53 = Waiver state — not calculated by PPS 54 = DRG < 001 or > 511, or = 214, 215, 221, 222, 438, 456, 457, 458 55 = Discharge date < provider effective start date or discharge date < MSA effective start date for PPS 56 = Invalid length of stay 57 = Review code invalid (Not 00, 03, 06, 07, 09) 58 = Total charges not numeric 61 = Lifetime reserve days not numeric or BILL-LTR-DAYS > 60 62 = Invalid number of covered days 65 = PAY-CODE not = A, B or C on provider specific file for capital 67 = Cost outlier with LOS > covered days ***Inpatient Rehab Facility (IRF) Pricer Return Codes*** IRF Payment return codes: 00 = Paid normal CMG payment without outlier 01 = Paid normal CMG payment with outlier 02 = Transfer paid on a per diem basis without outlier 03 = Transfer paid on a per diem basis with outlier 04 = Blended CMG payment — 2/3 federal PPS rate + 1/3 provider specific rate — without outlier 05 = Blended CMG payment — 2/3 federal PPS rate + 1/3 provider specific rate — with outlier 06 = Blended transfer payment — 2/3 federal PPS transfer rate + 1/3 provider specific rate — without outlier 07 = Blended transfer payment — 2/3 federal PPS transfer rate + 1/3 provider specific rate — with outlier 10 = Paid normal CMG payment with penalty without outlier 11 = Paid normal CMG payment with penalty with outlier 12 = Transfer paid on a per diem basis with penalty without outlier 13 = Transfer paid on a per diem basis with penalty with outlier 14 = Blended CMG payment — 2/3 federal PPS rate + 1/3 provider specific rate — with penalty without outlier 15 = Blended CMG payment — 2/3 federal PPS rate + 1/3 provider specific rate — with penalty with outlier 16 = Blended transfer payment — 2/3 federal PPS transfer rate + 1/3 provider specific rate — with penalty without outlier 17 = Blended transfer payment — 2/3 federal PPS transfer rate + 1/3 provider specific rate — with penalty with outlier IRF Error return codes: 50 = Provider specific rate not numeric 51 = Provider record terminated 52 = Invalid wage index 53 = Waiver state — not calculated by PPS 54 = CMG on claim not found in table 55 = Discharge date < provider effective start date or discharge date < MSA effective start date for PPS 56 = Invalid length of stay 57 = Provider specific rate zero when blended payment requested 58 = Total covered charges not numeric 59 = Provider specific record not found 60 = MSA wage index record not found 61 = Lifetime reserve days not numeric or BILL-LTR-DAYS > 60 62 = Invalid number of covered days 65 = Operating cost-to-charge ratio not numeric 67 = Cost outlier with LOS > covered days or cost outlier threshold calculation 72 = Invalid blend indicator (not 3 or 4) 73 = Discharged before provider FY begin date 74 = Provider FY begin date not in 2002 ***Long-Term Care Hospital (LTCH) Pricer Return Codes*** LTCH Payment return codes: 00 = Normal DRG payment without outlier 01 = Normal DRG payment with outlier 02 = Short stay payment without outlier 03 = Short stay payment with outlier 04 = Blend year 1 — 80% facility rate plus 20% normal DRG payment without outlier 05 = Blend year 1 — 80% facility rate plus 20% normal DRG payment with outlier 06 = Blend year 1 — 80% facility rate plus 20% short stay payment without outlier 07 = Blend year 1 — 80% facility rate plus 20% short stay payment with outlier 08 = Blend year 2 — 60% facility rate plus 40% normal DRG payment without outlier 09 = Blend year 2 — 60% facility rate plus 40% normal DRG payment with outlier 10 = Blend year 2 — 60% facility rate plus 40% short stay payment without outlier 11 = Blend year 2 — 60% facility rate plus 40% short stay payment with outlier 12 = Blend year 3 — 40% facility rate plus 60% normal DRG payment without outlier 13 = Blend year 3 — 40% facility rate plus 60% normal DRG payment with outlier 14 = Blend year 3 — 40% facility rate plus 60% short stay payment without outlier 15 = Blend year 3 — 40% facility rate plus 60% short stay payment with outlier 16 = Blend year 4 — 20% facility rate plus 80% normal DRG payment without outlier 17 = Blend year 4 — 20% facility rate plus 80% normal DRG payment with outlier 18 = Blend year 4 — 20% facility rate plus 80% short stay payment without outlier 19 = Blend year 4 — 20% facility rate plus 80% short stay payment with outlier 20 = Short stay payment based on estimated cost without outlier 21 = Short stay payment based on LTC- DRG per diem without outlier 22 = For long-term care PPS, it means short stay payment based on blend of LTC-DRG PER DIEM and IPPS comparable amount without outlier 23 = Short stay payment based on estimated cost with outlier 24 = Short stay payment based on LTC- DRG per diem with outlier 25 = Short stay payment based on blend of LTC-DRG per diem and IPPS comp amt with outlier 26 = For long-term care PPS, it means short stay payment based on IPPS- comparable threshold without outlier 27 = Short stay payment based on IPPS comparable threshold with outlier 28 = Subclause (II) without outlier 29 = Subclause (II) with outlier LTCH Error return codes: 50 = Provider specific rate not numeric 51 = Provider record terminated 52 = Invalid wage index 53 = Waiver state — not calculated by PPS 54 = DRG on claim not found in table 55 = Discharge date < provider effective start date or discharge date < MSA effective start date for PPS 56 = Invalid length of stay 57 = Provider specific rate zero when blended payment requested 58 = Total covered charges not numeric 59 = Provider specific record not found 60 = MSA wage index record not found 61 = Lifetime reserve days not numeric or lifetime reserve days greater than 60 62 = Invalid number of covered days or covered days < life time reserve days 65 = Operating cost-to-charge ratio not numeric 67 = Cost outlier with length of stay > covered days 68 = Provider specific state code invalid 72 = Invalid blend indicator (not 1 thru 5) 73 = Discharged before provider FY begin date 74 = Provider FY begin date not in 2002 A0 = Blend yr, site-neutral based on cost, psych/rehab A1 = Blend yr, site-neutral based on cost, outlier, psych/rehab A2 = Blend yr, site-neutral based on cost, SSO, psych/rehab A3 = Blend yr, site-neutral based on cost, SSO, outlier, psych/rehab A4 = Blend yr, site-neutral based on IPPS, psych/rehab A5 = Blend yr, site-neutral based on IPPS, outlier, psych/rehab A6 = Blend yr, site-neutral based on IPPS, SSO, psych/rehab A7 = Blend yr, site-neutral based on IPPS, SSO, outlier, psych/rehab AA = Site-neutral based on cost, psych/rehab AB = Site-neutral based on IPPS, psych/rehab AC = Site-neutral based on IPPS, outlier, psych/rehab B0 = Blend yr, site-neutral based on cost, vent B1 = Blend yr, site-neutral based on cost, outlier, vent B2 = Blend yr, site-neutral based on cost, SSO, vent B3 = Blend yr, site-neutral based on cost, SSO, outlier, vent B4 = Blend yr, site-neutral based on IPPS, vent B5 = Blend yr, site-neutral based on IPPS, outlier, vent B6 = Blend yr, site-neutral based on IPPS, SSO, vent B7 =Blend yr, site-neutral based on IPPS, SSO, outlier, vent BA = Site-neutral based on cost, vent BB = Site-neutral based on IPPS, vent BC = Site-neutral based on IPPS, outlier, vent BD = SSO standard payment, vent BE = SSO standard payment, outlier, vent BF = Standard payment full DRG, vent BG = Standard payment full DRG, outlier, vent C0 = Blend yr, site-neutral based on cost, no vent C1 = Blend yr, site-neutral based on cost, outlier, no vent C2 = Blend yr, site-neutral based on cost, SSO, no vent C3 = Blend yr, site-neutral based on cost, SSO, outlier, no vent C4 = Blend yr, site-neutral based on IPPS, no vent C5 = Blend yr, site-neutral based on IPPS, outlier, no vent C6 = Blend yr, site-neutral based on IPPS, SSO, no vent C7 = Blend yr, site-neutral based on IPPS, SSO, outlier, no vent CA = Site-neutral based on cost, no vent CB = Site-neutral based on IPPS, no vent CC = Site-neutral based on IPPS, outlier, no vent CD = SSO standard payment, no vent CE = SSO standard payment, outlier, no vent CF = Standard payment full DRG, no vent CG = Standard payment full DRG, outlier, no vent *************SNF Pricer Return Codes********* *******************TOB 21X******************* SNF payment return codes: 00 = RUG III group rate returned SNF Error return codes: 20 = Bad RUG code 30 = Bad MSA code 40 = Thru date < July 1, 1998 or invalid 50 = Invalid federal blend for that year 60 = Invalid federal blend 61 = Federal blend = 0 and SNF thru date < January 1, 2000 *********Hospice Pricer Return Codes************ **************TOB 81X or 82X******************** Hospice payment return codes: 00 = Home rate returned Hospice Error return codes: 10 = Bad units 20 = Bad units 2 < 8 30 = Bad MSA code 40 = Bad hospice wage index from MSA file 50 = Bad bene wage index from MSA file 51 = Bad provider number *******Home Health Pricer Return Codes************ *****TOB 32X or 33X, DOS 10/1/2000 and after****** Home health payment return codes: 00 = Final payment where no outlier applies 01 = Final payment where outlier applies 03 = Initial percentage payment, 0% 04 = Initial percentage payment, 50% 05 = Initial percentage payment, 60% 06 = LUPA payment only 07 = Final payment, SCIC 08 = Final payment, SCIC with outlier 09 = Final payment, PEP 11 = Final payment, PEP with outlier 12 = Final payment, SCIC within PEP 13 = Final payment, SCIS within PEP with outlier Home health error return codes: 10 = Invalid TOB 15 = Invalid PEP days 16 = Invalid HRG days, > 60 20 = PEP indicator invalid 25 = Med review indicator invalid 30 = Invalid MSA code 35 = Invalid initial payment indicator 40 = Dates < October 1, 2000 or invalid 70 = Invalid HRG code 75 = No HRG present in 1st occurrence 80 = Invalid revenue code 85 = No revenue code present on HH final claim/adjustment ************Outpatient PPS Pricer Return Codes****** Outpatient PPS payment return codes: 01 = Line processed to payment 20 = Line processed but payment = 0 bene deductible = > adjusted payment 22 = For outpatient PPS, it means daily coinsurance limitation Outpatient PPS error return codes: 30 = Missing, deleted, or invalid APC 38 = Missing or invalid discount factor 40 = Invalid service indicator passed by the OCE 41 = Service indicator invalid for OPPS PRICER 42 = APC = “00000” or (packaging flag = 1 or 2) 43 = Payment indicator not = to 1 or 5 thru 9 44 = Service indicator = “H” but payment indicator not = to 6 45 = Packaging flag not = to 0 46 = Line-item denial/reject flag not = to 0 or line-item denial/reject flag = to 1 and (APC not = 0033 or 0034 or 0322 or 0323 or 0324 or 0325 or 0373 or 0374)) or line-item action flag not = to 1 47 = Line-item action flag = 2 or 3 48 = Payment adjustment flag not valid 49 = Site of service flag not = to 0 or (APC 0033 is not on the claim and service indicator = “P” or APC = 0322, 0325, 0373, 0374) 50 = Wage index not located 51 = Wage index equals zero 52 = Provider specific file wage index reclassification code invalid or missing 53 = Service from date not numeric or < 20000801 54 = Service from date < provider effective date or service from date > provider termination date ***End-stage Renal Disease (ESRD) Pricer Return Codes*** ESRD payment return codes: 00 = ESRD PPS payment calculated 01 = ESRD facility rate > zero ESRD error return codes: 22 = For ESRD Pricer, it means PPS w/acute comorbid, training 26 = For ESRD Pricer, it means PPS w/chronic comorbid, low volume, training 31 = ESRD Pricer means PPS w/low BMI 32 = ESRD Pricer means PPS w/low volume, onset 33 = For ESRD Pricer, it means PPS w/outlier, training 50 = ESRD facility rate not numeric 52 = Provider type not = “40” or “41” 53 = Special payment indicator not = “1” or blank 54 = Date of birth not numeric or = zero 55 = Patient weight not numeric or = zero 56 = Patient height not numeric or = zero 57 = Revenue center code not in range 58 = Condition code not = “73” or “74” or blank 60 = MSA wage adjusted rate record not found 98 = Claim through date before 4/1/2005 or not numeric