Description
Medicare Perspective Payment Systems:
Medicare Institutional Data (CMS-1450/ UB-04 / ANSI 837i)
- Hospital acute inpatient (IPPS / MS-DRG)
- Hospital outpatient (OPPS)
- Ambulatory surgery center (ASC)
- Durable Medical Equipment (DME)
- End stage renal disease (ESRD with “composite” rates and OPPS/Fee Schedule)
- Skilled nursing facilities (SNF)
- Inpatient rehabilitation facilities (IRF)
- Inpatient psychiatric facility (IPF)
- Long term care hospital (LTCH)
- Outpatient rehabilitation facility (ORF)
- Critical access hospitals (CAH)
- Sole community hospitals (DRG plus an SCH “add on”)
- Comprehensive outpatient rehabilitation facilities (CORF)
- Rural health clinic (RHC)
- Hospice, federally qualified health centers for IP and OP (FQHC)
- Community mental health centers (CMHC)
- Swing bed
- Ambulance
- Home health agency (HHA)
Medicare Professional Data (CMS-1500/ HCFA-1500 / ANSI 837p)
- Professional / physician (RBRVS) including all localities
- Parenteral and Enteral nutrition (PEN)
- Drugs
- Clinical labs
- Prosthetics, orthotics and surgical suppliers (POS)
Claim Edits
- Diagnosis Code Validation
- Local Coverage Determination (LCD)
- National Coverage Determination (NCD)
- Age Edits
- Gender Edits
- Outpatient Code Edits (IOCE)
- Medically Unlikely Edits (MUE)
- Correct Code Initiative (NCCI)
- CPT Edits
- RVU Edits
- Modifier Edits
