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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