Examples of Optional Claims Screens 9. Suspend pay for second office visit (procedures 90015 and 90060) in 1 month for same diagnosis. 10. Allow one office consultation (procedures 90600 through 90620) per month for same diagnosis. Reduce additional claims in the same month to procedure 90640. Appendix V Contents of Selected Medicare Statistical Files Inpatient Hospital and The discussion below and accompanying tables describe the data included in the HCFA Medicare files summarized in chapter 5. For each data element listed for each Medicare file, we have indicated, where appropriate, information that could be used to describe individual patient characteristics or the structure, process, or outcomes of care. Table V.1 contains billing and demographic information on beneficiary Inpatient stay file content 17. HMO effective date 18. HMO termination date 19. HMO number 20. HMO option code 21. Bill covers period a. From date b. Through date 22. Query code 23. Transaction code 24. Adjustment code 29. Intermediary number 31. Date forwarded 32. Date of admission 33. Patient status code 34. Discharge date 35. Date of death 36. Total covered days 37. Cost report days X Inpatient stay file content 51. Blood pints furnished 52. Blood pints replaced 54. Blood charge per pint 55 Total blood charges 56 Total blood noncovered charges 57. Noncovered from date 58. Noncovered through date 59. Open item from date 60. Open item through date 61. Nonpayment code 62. Total charges 63. Reimbursement amount 64. Diagnostic data a. Number of diagnostic codes b. Principal diagnosis code c. Additional diagnosis 65. Surgery data a. Number of surgery codes b. Principal surgery c. Additional surgery d. Date of surgery 66. Noncovered charges 67. End-stage renal disease indicator 68. Qualifying dates a. From date b. To date 69. DRG number 70. Discharge destination 71. DRG outlier code 72. Date guarantee of payment began 73. Date utilization review notice received 74. Date active care ended 75. Date benefits exhausted 76. Outlier amount 77. HMO paid/readmission indicator 78. KRON indicatorb 79. Value code 80. Value code amount aThe system to provide immediate data on eligibility for reimbursement (SPIDER) is a HCFA data system under development. bProvides information about the bill's Medicare spell-of-illness status. Medicare Provider The Medicare provider analysis and review file is derived from the inpatient hospital stay record and the provider of services file. Characteristics of the provider are added to selected fields from the hospital stay record. The file is prepared every 3 months and contains 3 years of discharges (the current year and 2 previous years). Table V.2 illustrates this file. |