01 = Most common semi-private rate — to provide for the recording of hospital's most common semi-private rate
02 = Hospital has no semi-private rooms — entering this code requires $0.00 amount
03 = Reserved for national assignment
04 = Inpatient professional component charges which are combined billed — for use only by some all-inclusive rate hospitals
05 = Professional component included in charges and also billed separately to carrier — for use on Medicare and Medicaid bills if the state requests this information
06 = Medicare blood deductible — total cash blood deductible (Part A blood deductible)
07 = Medicare cash deductible reserved for national assignment
08 = Medicare Part A lifetime reserve amount in first calendar year — lifetime reserve amount charged in the year of admission
09 = Medicare Part A coinsurance amount in the first calendar year — coinsurance amount charged in the year of admission
10 = Medicare Part A lifetime reserve amount in the second calendar year — lifetime reserve amount charged in the year of discharge where the bill spans two calendar years
11 = Medicare Part A coinsurance amount in the second calendar year — coinsurance amount charged in the year of discharge where the bill spans two calendar years
12 = Amount is that portion of higher priority EGHP insurance payment made on behalf of aged bene provider applied to Medicare covered services on this bill. Six zeroes indicate provider claimed conditional Medicare payment
13 = Amount is that portion of higher priority EGHP insurance payment made on behalf of ESRD bene provider applied to Medicare covered services on this bill. Six zeroes indicate the provider claimed conditional Medicare payment
14 = That portion of payment from higher priority no fault auto/other liability insurance made on behalf of bene provider applied to Medicare covered services on this bill. Six zeroes indicate provider claimed conditional payment
15 = That portion of a payment from a higher priority WC plan made on behalf of a bene that the provider applied to Medicare covered services on this bill. Six zeroes indicate the provider claimed conditional Medicare payment
16 = That portion of a payment from higher priority PHS or other federal agency made on behalf of a bene the provider applied to Medicare covered services on this bill. Six zeroes indicate provider claimed conditional Medicare payment
17 = Operating outlier amount — providers do not report this. For payer internal use only. Indicates the amount of day or cost outlier payment to be made. (Do not include any PPS capital outlier payment in this entry)
18 = Operating disproportionate share amount — providers do not report this. For payer internal use only. Indicates the disproportionate share amount applicable to the bill. Use the amount provided by the disproportionate share field in PRICER. (Do not include any PPS capital DSH adjustment in this entry)
19 = Inpatient use. Operating indirect medical education amount — the A/B MAC (A) reports operating indirect medical education amount applicable. It uses the amount provided by the indirect medical education field in PRICER. It does not include any PPS capital IME adjustment in this entry
Outpatient use. The Medicare shared system will display this payer only code on the claim for low volume providers to identify the amount of the low volume adjustment being included in the provider’s reimbursement. This payer only code 19 is also used for IME on hospital claims. This instruction shall only apply to ESRD bill type 72x and must not impact any existing instructions for other bill types
20 = Total payment sent provider for capital under PPS, including HSP, FSP, outlier, old capital, DSH adjustment, IME adjustment, and any exception amount
21 = Catastrophic — Medicaid — eligibility requirements to be determined at state level
22 = Surplus — Medicaid — eligibility requirements to be determined at state level
23 = Recurring monthly income — Medicaid — eligibility requirements to be determined at state level
24 = Medicaid rate code — Medicaid — eligibility requirements to be determined at state level
25 = Offset to the patient payment amount (prescription drugs) — prescription drugs paid for out of a long-term care facility resident/patient's fund in the billing period submitted (statement covers period)
26 = Prescription drugs offset to patient (payment amount — hearing and ear services) hearing and ear services paid for out of a long-term care facility resident/patient's funds in the billing period submitted (statement covers period)
27 = Offset to the patient (payment amount — vision and eye services) — vision and eye services paid for out of a long-term care facility resident/patient's funds in the billing period submitted (statement covers period)
28 = Offset to the patient (payment amount — dental services) — dental services paid for out of a long-term care facility resident/patient's funds in the billing period submitted (statement covers period)
29 = Offset to the patient (payment amount — chiropractic services) — chiropractic services paid for out of a long-term care facility resident/patient's funds in the billing period submitted (statement covers period)
30 = Preadmission testing — the code used to reflect the charges for preadmission outpatient diagnostic services in preparation for a previously scheduled admission
31 = Patient liability amount — amount shown is that which you or the PRO approved to charge the bene for non-covered accommodations, diagnostic procedures, or treatments
32 = Multiple patient ambulance transport — the number of patients transported during one ambulance ride to the same destination. (eff. 4/2003)
33 = Offset to the patient payment amount (podiatric services) — podiatric services paid out of a long-term care facility resident/patient's funds in the billing period submitted
34 = Offset to the patient payment amount (medical services) — other medical services paid out of a long-term care facility resident/patient's funds in the billing period submitted
35 = Offset to the patient payment amount (health insurance premiums) — other medical services paid out of a long-term care facility resident/ patient's funds in the billing period submitted
37 = Pints of blood furnished — total number of pints of whole blood or units of packed red cells furnished to the patient
38 = Blood deductible pints — the number of unreplaced pints of whole blood or units of packed red cells furnished for which the patient is responsible
39 = Pints of blood replaced — the total number of pints of whole blood or units of packed red cells furnished to the patient that have been replaced by or on behalf of the patient
40 = New coverage not implemented by HMO — amount shown is for inpatient charges covered by HMO. (use this code when the bill includes inpatient charges for newly covered services which are not paid by HMO
41 = Amount is that portion of a payment from higher priority BL program made on behalf of bene the provider applied to Medicare covered services on this bill. Six zeroes indicate the provider claimed conditional Medicare payment
42 = VA or PACE
43 = Disabled bene under age 65 with LGHP — amount is that portion of a payment from a higher priority LGHP made on behalf of a disabled Medicare bene the provider applied to Medicare covered services on this bill
44 = Amount provider agreed to accept from primary payer when amount less than charges, but more than payment received — when a lesser amount is received and the received amount is less than charges, a Medicare secondary payment is due
45 = Accident hour — the hour the accident occurred that necessitated medical treatment
46 = Number of grace days — following the date of the PRO/UR determination, this is the number of days determined by the PRO/UR to be necessary to arrange for the patient's post-discharge care
47 = Any liability insurance — amount is that portion from a higher priority liability insurance made on behalf of Medicare bene the provider is applying to Medicare covered services on this bill
48 = Hemoglobin reading — the patient's most recent hemoglobin reading taken before the start of the billing period (eff. 1/2006). Prior to 1/2006 defined as the latest hemoglobin reading taken during the billing cycle
49 = Hematocrit reading — the patient's most recent hematocrit reading taken before the start of the billing period (eff. 1/2006). Prior to 1/2006 defined as hematocrit reading taken during the billing cycle
50 = Physical therapy visits — indicates the number of physical therapy visits from onset (at billing provider) through this billing period
51 = Occupational therapy visits — indicates the number of occupational therapy visits from onset (at the billing provider) through this billing period
52 = Speech therapy visits — indicates the number of speech therapy visits from onset (at billing provider) through this billing period
53 = Cardiac rehabilitation — indicates the number of cardiac rehabilitation visits from onset (at billing provider) through this billing period
54 = New birth weight in grams — actual birth weight or weight at time of admission for an extramural birth. Required on all claims with type of admission of “4” and on other claims as required by law
55 = Eligibility threshold for charity care — code identifies the corresponding value amount at which a health care facility determines the eligibility threshold of charity care
56 = Hours skilled nursing provided — the number of hours skilled nursing provided during the billing period. Count only hours spent in the home
57 = Home health visit hours — the number of home health aide services provided during the billing period. Count only the hours spent in the home
58 = Arterial blood gas — arterial blood gas value at beginning of each reporting period for oxygen therapy. This value or value 59 will be required on the initial bill for oxygen therapy and on the fourth month's bill
59 = Oxygen saturation — oxygen saturation at the beginning of each reporting period for oxygen therapy. This value or value 58 will be required on the initial bill for oxygen therapy and on the fourth month's bill
60 = HHA branch MSA — MSA in which HHA branch is located
61 = Location of HHA service or hospice service — the Balanced Budget Act (BBA) requires that the geographic location of where the service was provided be furnished instead of the geographic location of the provider. NOTE: HHA claims with a thru date on or before 12/2005, the value code amount field reflects the MSA code (followed by zeroes to fill the field). HHA claims with a thru date after 12/2005, the value code amount field reflects the CBSA code
62 = Payer only — on type of bill 032x: HH visits Part A — the number of visits determined by Medicare to be payable from the Part A Trust Fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by §1812(a)(3) of the Social Security Act. On type of bills 081x or 082x: Number of high routine home care days — days that fall within the first 60 days of a routine home care hospice claim)
63 = Payer only — on type of bill 032x: HH visits — Part B — the number of visits determined by Medicare to be payable from the Part B trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by §1812(a)(3) of the Social Security Act. On type of bills 081x or 082x: Number of low routine home care days — days that come after the first 60 days of a routine home care hospice claim
64 = Payer only HH reimbursement — Part A — the dollar amounts determined to be associated with the HH visits identified in a value code 62 amount. This Part A payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by §1812(a)(3) of the Social Security Act.
65 = Payer only HH reimbursement — Part B — the dollar amounts determined to be associated with the HH visits identified in a value code 63 amount. This Part B payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act
66 = Medicare spend-down amount — the dollar amount that was used to meet the recipient's spend-down liability for this claim
67 = Peritoneal dialysis — the number of hours of peritoneal dialysis provided during the billing period (only the hours spent in the home)
68 = EPO drug — number of units of EPO administered relating to the billing period
69 = State charity care percent — code indicates the percentage of charity care eligibility for the patient
70 = Interest amount — (providers do not report this.) Report the amount applied to this bill
71 = Funding of ESRD networks — (providers do not report this.) Report the amount the Medicare payment was reduced to help fund the ESRD networks
72 = Flat rate surgery charge — code indicates the amount of the charge for outpatient surgery where the hospital has such a charging structure
73 = Sequestration adjustment amount
74 = Low volume hospital payment amount
75 = Prior covered days for an interrupted stay
76 = Provider’s interim rate — report provider's percentage of billed charges interim rate during billing period. Applies to OP hospital, SNF and HHA claims where interim rate is applicable. Report to left of dollar/cents delimiter. (TP payers internal use only). An interim rate of 50 percent is entered as follows: 50.00
77 = New technology add-on payment amount — amount of payments made for discharges involving approved new technologies. If the total covered costs of the discharge exceed the DRG payment for the case (including adjustments for IME and disproportionate share hospitals (DSH) but excluding outlier payments) an add-on amount is made indicating a new technology was used in the treatment of the beneficiary. (eff. 4/2003, under inpatient PPS)
78 = Off-site zip code — when the facility zip (Loop 2310E N403 Segment) is present for the following bill types: 012X, 013X, 014X, 022X, 023X, 034X, 072X, 074X, 075X, 081X, 082X, and 085X. The ZIP code is associated with this value and is used to price MPFS HCPCS and anesthesia services for CAH Method II
79 = Total payments for services applicable to the ESRD — the Medicare shared system will display this payer only code on the claim. The value represents the dollar amount for Medicare allowed payments applicable for the calculation in determining an outlier payment
80 = Covered days — the number of days covered by the primary payer
81 = Non-covered days — days of care not covered by the primary payer
82 = Coinsurance days — the inpatient Medicare days occurring after the 60th day and before the 91st day or inpatient SNF/swing bed days occurring after the 20th and before the 101st day in a single spell of illness
83 = Lifetime reserve days — under Medicare, each beneficiary has a lifetime reserve of 60 additional days of inpatient hospital services after using 90 days of inpatient hospital services during a spell of illness
84 = Medicare lifetime reserve amount — in the third or greater calendar years (eff. 1/2013
85 = Medicare coinsurance amount in the third or greater calendar years (eff. 1/2013)
86 = Invoice cost (for CAR T-cells) (eff. 04/2019, term. 3/2020)
87 = Gene therapy invoice cost (eff. 4/2020)
88 = Allogeneic stem cell transplant — number of related donors’ evaluation (eff. 7/2020)
89 = Allogeneic stem cell transplant — total all-inclusive donor charges (eff. 7/2020)
90 = Cell therapy invoice cost (eff. 4/2020)
91 = Charges for kidney acquisition (eff. 10/2021)
92–99 = Reserved for national assignment
A0 = Special zip code reporting — five-digit zip code of the location from which the beneficiary is initially placed on board the ambulance (eff. 9/2001)
A1 = Deductible payer A — the amount assumed by the provider to be applied to the patient's deductible amount to the involving the indicated payer. (eff. 10/1993) — prior value 0
A2 = Coinsurance payer A — the amount assumed by the provider to be applied to the patient's Part B coinsurance amount involving the indicated payer
A3 = Estimated responsibility payer A — the amount estimated by the provider to be paid by the indicated payer
A4 = Self-administered drugs administered in an emergency situation — ordinarily the only non-covered self-administered drug paid for under Medicare in an emergency situation is insulin administered to a patient in a diabetic coma
A5 = Covered self-administered drugs — the amount included in covered charges for self-administrable drugs administered to the patient because the drug was not self-administered in the form and situation in which it was furnished to the patient
A6 = Covered self-administered drugs — diagnostic study and other — the amount included in covered charges for self-administrable drugs administered to the patient because the drug was necessary for diagnostic study or other reasons. For use with revenue center 0637
A7 = Copayment A — the amount assumed by the provider to be applied toward the patient's copayment amount involving the indicated payer
A8 = Patient weight — weight of patient in kilograms. Report this data only when the health plan has a predefined change in reimbursement that is affected by weight
A9 = Patient height — height of patient in centimeters. Report this data only when the health plan has a predefined change in reimbursement that is affected by height
AA = Regulatory surcharges, assessments, allowances or health care related taxes (payer A) — the amount of regulatory surcharges, assessments, allowances, or health care related taxes pertaining to the indicated payer (eff. 10/2003)
AB = Other assessments or allowances (payer A) — the amount of other assessments or allowances pertaining to the indicated payer (eff. 10/2003)
B1 = Deductible payer B — the amount assumed by the provider to be applied to the patient's deductible amount involving the indicated payer (eff. 10/1993) — prior value 07
B2 = Coinsurance payer B — the amount assumed by the provider to be applied to the patient's Part B coinsurance amount involving the indicated payer
B3 = Estimated responsibility payer B — the amount estimated by the provider to be paid by the indicated payer
B7 = Copayment B — the amount assumed by the provider to be applied toward the patient's copayment amount involving the indicated payer
BA = Regulatory surcharges, assessments, allowances or health care related taxes (payer B) — the amount of regulatory surcharges, assessments, allowances, or health care related taxes pertaining to the indicated payer (eff. 10/2003)
BB = Other assessments or allowances (payer B) — the amount of other assessments or allowances pertaining to the indicated payer. (eff. 10/2003)
C1 = Deductible payer C — the amount assumed by the provider to be applied to the patient's deductible amount involving the indicated payer. (eff. 10/1993) — prior value 07
C2 = Coinsurance payer C — the amount assumed by the provider to be applied to the patient's Part B coinsurance amount involving the indicated payer
C3 = Estimated responsibility payer C
C7 = Copayment C — the amount assumed by the provider to be applied toward the patient's copayment amount involving the indicated payer
CA = Regulatory surcharges, assessments, allowances or health care related taxes (payer C) — the amount of regulatory surcharges, assessments, allowances, or health care related taxes pertaining to the indicated payer (eff. 10/2003)
CB = Other assessments or allowances (payer C) — the amount of other assessments or allowances pertaining to the indicated payer (eff. 10/2003)
D3 = Estimated responsibility patient — the amount estimated by the provider to be paid by the indicated patient
D4 = Clinical trial number assigned by NLM/NIH — eight-digit numeric National Library of Medicine/National Institute of Health clinical trial registry number or a default number of “99999999” if the trial does not have an 8-digit registry number. (eff. 10/2007)
D5 = Result of last Kt/V. For in-center hemodialysis patients, this is the last reading taken during the billing period. For peritoneal dialysis patients (and home hemodialysis patients), this may be before the current billing period but should be within 4 months of the date of service (eff. 7/1/10)
D6 = Total number of minutes of dialysis provided during the billing period (eff. 1/2021)
E1 = Deductible payer D
E3 = Estimated responsibility payer D
F1 = Deductible payer E
F2 = Coinsurance payer E
F3 = Estimated responsibility payer E
FC = Patient paid amount — the amount the provider has received from the patient toward payment of this bill (7/2008)
FD = Credit received from the manufacturer for a replaced medical device — the amount the provider has received from a medical device manufacturer as credit for a replaced device. (eff. 7/2008)
G1 = Deductible payer F
G2 = Coinsurance payer F
G3 = Estimated responsibility payer F
G8 = Facility where inpatient hospice service is delivered — MSA or Core Based Statistical Area (CBSA) number (or rural state code) of the facility where inpatient hospice is delivered. (eff. 1/2008)
GA = Regulatory surcharges, assessments, allowances or health care related taxes payer F
P0 = Reserved for public health data reporting
P1 = Heart rate (eff. 7/2019)
P2 = Blood pressure — systolic (eff. 7/2019)
P3 = Blood pressure — diastolic (eff. 7/2019)
Q0 = Pioneer Accountable Care Organization (ACO) non-model payment or Next Generation ACO non-model payment
Q1 = Pioneer ACO model payment amount including reduction or NG ACO payment amount including reduction)
Q2 = Hospice claim paid from Part B Trust Fund
Q3 = Prior authorization 25% penalty
Q4 = Pennsylvania (PA) rural health exclusion — physician services claim reimbursement
Q5 = Electronic health record (EHR) reduction
Q6 = PQRS
Q7 = Islet add-on payment amount (eff. 10/2016)
Q8 = Total transitional drug add-on payment adjustment (TDAPA) amount (eff. 1/2018)
Q9 = Medicare Advantage (MA) plan amount (eff. 10/2014)
QA = PHP partial week input
QB = ESRD Treatment Choices (ETC) Model: Home Dialysis Payment Adjustment (HDPA) total bonus paid
QC = OCM+ payment adjustment amount (payer only) — (eff. 1/2020)
QD = Device credit
QE = ET3 Model – ET3 15% bonus payment
QF = HHA — LATE-SUB-PENALTY-AMT
QG = Total Transitional Add-on Payment Adjustment for New and Innovative Equipment and Supplies (TPNIES) amount — used to capture the add-on payment (eff. 4/2021)
QH = Total TPNIES CRA amount — used to capture the add-on payment. (payer only) (eff. 1/2022)
QI = Maryland Primary Care Program (MDPCP) Federally Qualified Health Center (FQHC) demo — used to capture reduction amounts (payer only) (eff. 1/2022)
QJ = ESRD treatment choices (ETC) facility performance payment adjustment (PPA) (payer only) (eff. 7/2022)
QK = Maryland waiver kidney acquisition payment
QM = MIPS adjustment amount
QN = First APC pass-through device offset
QO = Second APC pass-through device offset
QP = Reserved for future use
QQ = Terminated procedure with pass-through device OR condition for device credit present
QR = First APC pass-through drug or biological offset
QS = Second APC pass-through drug or biological offset
QT = Third APC pass-through drug or biological offset
QU = Device credit with device offset
QV = Value based purchasing adjustment amount
QW = PHP partial week output
XX = Total charge amount for all Part A visits on RIC “U” claims — for home health claims containing both Part A and Part B services this code identifies the total charge amount for the Part A visits (based on revenue center codes 042X, 043X, 044X, 055X, 056X, and 057X). Code created internally in the NCHMQA system (eff. 10/2001 with HHPPS)
XY = Total charge amount for all Part B visits on RIC “U” claims — for home health claims containing both Part A and Part B services this code identifies the total charge amount for the Part B visits (based on revenue center codes 042X, 043X, 044X, 055X, 056X, and 057X). Code created internally in the NCHMQA system (eff. 10/2001 with HHPPS)
XZ = Total charge amount for all Part B non-visit charges on the RIC “U” claims — for home health claims containing both Part A and Part B services, this code identifies the total charge amount for the Part B non-visit charges. Code created internally in the NCHMQA system (eff. 10/2001 with HHPPS)
Y1 = Part A demo payment — portion of the payment designated as reimbursement for Part A services under the demonstration. Amount instead of the traditional prospective DRG payment (operating and capital) as well as any outlier payments that might have been applicable in the absence of the demonstration. No deductible or coinsurance has been applied. Payments for operating IME and DSH processed traditionally are also not included in this amount
Y2 = Part B demo payment — portion of the payment designated as reimbursement for Part B services under the demonstration. No deductible or coinsurance has been applied
Y3 = Part B coinsurance — amount of Part B coinsurance applied by the intermediary to this demo claim. For demonstration claims this will be a fixed copayment unique to each hospital and DRG (or DRG/procedure group)
Y4 = Conventional provider payment amount for non-demonstration claims — this the amount Medicare would have reimbursed the provider for Part A services if there had been no demonstration. This should include the prospective DRG payment (both capital as well as operational) as well as any outlier payment, which would be applicable. It does not include any pass-through amounts such as that for direct medical education nor interim payments for operating IME and DSH
Y5 = Part B deductible, applicable for a model 4 demonstration 64 claims
Z9 = COVID-19 PHE end date