CLM_VAL_TB Claim Value Table 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. (Eff 9/93) 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 (term 9/30/93) Reserved for national assignment. 08 = Medicare Part A lifetime reserve amount in first calendar year - Lifetime reserve amount charged in the year of admission. (not stored in NCH until 2/93) 09 = Medicare Part A coinsurance amount in the first calendar year - Coinsurance amount charged in the year of admission. (not stored in NCH until 2/93) 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. (in NCH until 2/93) 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 (not stored in NCH until 2/93) 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). Obsolete 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 adjust- ment in this entry). Obsolete 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. (used 10/1/91 - 3/1/92 for provider reporting. Payer only code eff 9/93.) Obsolete 21 = Catastrophic - Medicaid - Eligibility requirements to be determined at state level. (Medicaid specific/deleted 9/93) 22 = Surplus - Medicaid - Eligibility requirements to be determined at state level. (Medicaid specific/deleted 9/93) 23 = Recurring monthly income - Medicaid - Eligibility requirements to be determined at state level. (Medicaid specific/deleted 9/93) 24 = Medicaid rate code - Medicaid - Eligibility requirements to be determined at state level. (Medicaid specific/deleted 9/93) 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 (State- ment 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 - Chiro- practic Services) - Chiropratic 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 diag- nostic 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 noncovered accommodations, diagnostic procedures or treatments. 32 = Multiple patient ambulance transport - The number of patients transported during one ambulance ride to the same destination. (eff. 4/1/2003) 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. (eff 10/93) 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. (eff 10/93) 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. (eff 10/93) 40 = New coverage not implemented by HMO - amount shown is for inpatient charges covered by HMO (eff 3/92). (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 Black Lung federal 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 = Amount is that portion of a payment from higher priority VA made on behalf of bene the provider applied to Medicare covered services on this bill. Six zeroes indicate the provider claimed conditional Medicare payment. 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. (eff 10/93) 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. (Eff 9/93) 48 = Hemoglobin reading - The patient's most recent hemoglobin reading taken before the start of the billing period (eff. 1/3/2006). Prior to 1/3/2006 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. 1/3/2006). Prior to 1/3/2006 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 12/31/05, the value code amount field reflects the MSA code (followed by zeroes to fill the field). HHA claims with a thru date after 12/31/05, the value code amount field reflects the CBSA code. 62 = Number of Part A home health visits accrued during a period of continuous care - necessitated by the change in payment basis under HH PPS (eff. 10/00) 63 = Number of Part B home health visits accrued during a period of continuous care - necessitated by the change in payment basis under HH PPS (eff. 10/00) 64 = Amount of home health payments attributed to the Part A trust fund in a period of continuous care - necessitated by the change in payment basis under HH PPS (eff. 10/00) 65 = Amount of home health payments attributed to the Part B trust fund in a period of continuous care - necessitated by the change in payment basis under HH PPS (eff. 10/00) 66 = Medicare Spend-down Amount -- The dollar amount that was used to meet th4e 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). (eff. 10/97) 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 = 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) 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 disporportionate 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. 4/1/03, 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 as qualified by the payer. 81 = Non-covered Days - days of care not covered by the primary payer. 82 = Co-insurance 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. 1/7/2013 85 = Medicare Coinsurance Amount in the third or greater calendar years'. Eff. 1/7/2013 86 = Invoice Cost (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 - 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. 9/01) A1 = Deductible Payer A - The amount assumed by the provider to be applied to the patient's deductible amount to the invovling the indicated payer. (eff. 10/93) - Prior value 07 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. (eff 10/93) 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 noncovered self-administered drug paid for under Medicare in an emergency situation is insulin administered to a patient in a diabetic coma. (eff 7/97) A5 = Covered self-administered drugs -- The amount included in covered charges for self-admini- strable drugs administered to the patient be- cause 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 pro- vider to be applied toward the patient's co- payment 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 per- taining 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 10/93) - 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. (eff 10/93) 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 pro- vider to be applied toward the patient's co- payment 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 per- taining 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 10/93) - 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. (eff 10/93) C3 = Estimated Responsibility Payer C - The C7 = Copayment C -- The amount assumed by the pro- vider to be applied toward the patient's co- payment 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 per- taining 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. 10/1/07) D5 = Last Kt/V Reading - result of last Kt/V reading. 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) FC = Patient Paid Amount - The amount the provider has received from the patient toward payment of this bill (7/1/08). 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. 7/1/08) 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. 1/1/08) 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 = 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 = OCM+ Payment Adjustment Amount (payer only) (eff. 1/2020) QD = Device Credit QG = Total TPNIES Amount - used to capture the TPNIES 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) QM = MIPS adjustment amount QN = First APC pass-through device offset QO = Second APC pass-through device offset QP = Third APC pass-through device offset 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, & 057X). Code created internally in the CWFMQA system (eff. 10/31/01 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, & 057X). Code created internally in the CWFMQA system (eff. 10/31/01 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 & Part B services, this code identifies the total charge amount for the Part B non-visit charges. Code created internally in the CWFMQA system (eff. 10/31/01 with HHPPS). Y1 = Part A demo payment - Portion of the payment designated as reimbursement for Part A services under the demonstration. This amount is 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 which are pro- cessed in the traditional manner 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 reim- bursed 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