Using the Carrier File - ResDACresdac.umn.edu/sites/resdac.umn.edu/files/Using the Carrier...
Transcript of Using the Carrier File - ResDACresdac.umn.edu/sites/resdac.umn.edu/files/Using the Carrier...
Using the Carrier File (FORMERLY CALLED THE PHYSICIAN/SUPPLIER PART B FILE)
Marshall McBean, M.D., M.Sc.
Director of ResDAC
University of Minnesota
The important groups of Carrier File variables from the CMS 1500 form
Claim “Header” or “Fixed Portion” variables. The
“header” portion of CMS 1500 form, including the
diagnoses. Called “Base Claim File” portion in
CCW/Buccaneer record layout.
- Note: The patient characteristics (demographics) which
were only in the CCW Beneficiary Summary File are now
in the CCW claims files, too.
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The important groups of Carrier File variables from the CMS 1500 form
Line Item variables. Those variables found in the
“Trailer” portion of the CMS 1500 form. Called
“Line File” portion in CCW/Buccaneer record
layout.
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Carrier File Data Dictionaries
CCW data dictionary:
http://www.ccwdata.org/data-
dictionaries/index.htm
Classic CMS Carrier file data dictionary:
http://www.resdac.org/cms-data/files/carrier-
rif/data-documentation
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Useful variables in the Base Claim File portion of the Carrier File
Information about the beneficiary
- BENE_ID (Encrypted)
- Beneficiary demographics
» Date of birth
» Gender
» Race/ethnicity
- Beneficiary place of residence
» State, county and zip code
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Useful variables in the Line File portion of the Carrier File
Information about the claim
- Claim From Date
- Claim Through Date
- Claim Payment Amount
- Claim Diagnosis Codes
» occurs up to 8 times (starting with 2007 data)
» uses ICD-9-CM codes – ICD-10 is coming October 2014
» diagnosis of XX000 = a laboratory test
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Carrier File Diagnoses
“By rule”, there should be no “rule-outs”
Diagnoses that are found in the line items are
truly also in the claim file portion of the record
Determination of co-morbidities is an issue as
discussed by Beth in her presentation of MedPAR
file
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Useful variables in the Line File portion of the Carrier File
Note: a line item or Line File portion may occur up
to 13 times on one claim
- No longer a “count variable”
Line Diagnosis Code
- It can be any of the up to 8 possible diagnoses in the
claim file portion of the Carrier File
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Useful variables in the Line File portion of the Carrier File
3 variables useful for linking Carrier claims to MedPAR hospital or to outpatient claims
1. Line Place of Service Code
2 and 3. Dates of service (Line First Expense Date and Line Last Expense Date)
Reasons to link the claims:
1. to sum the amount reimbursed for care,
2. to “validate” the occurrence of a procedure 3. to avoid duplicate counting of cases or procedures
4. Others?
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Examples of line place of service codes
11 = Office
12 = Home
21 = Inpatient hospital
22 = Outpatient hospital
23 = Emergency room - hospital
24 = Ambulatory surgical center
31 = Skilled nursing facility
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Additional examples of line place of service codes
32 = Nursing facility
33 = Custodial care facility
34 = Hospice
35 = Adult living care facilities (ALCF) (eff. NYD –
added 12/3/97)
41 = Ambulance - land
42 = Ambulance - air or water
50 = Federally qualified health centers
(eff. 10/1/93)
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More useful variables in the Line File portion of the Carrier File
Line Healthcare Common Procedure Coding
System (HCPCS) Code
Line HCPCS Initial Modifier Code
Line HCPCS Second Modifier Code
Line HCPCS Third Modifier Code
Line HCPCS Fourth Modifier Code
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HCPCS: Healthcare Common Procedure Coding System Codes
Level 1 - 5 position numeric codes -- are CPT (Current
Procedural Terminology) Codes of American Medical
Association
- e.g., 99201 Office or other outpatient visit for the
evaluation and management of new patient
Level 2 - 5 position alpha-numeric codes
- e.g., J0540 Injection, penicillin G benzathine and
penicillin G procaine, up to 1,200,000 units
Level 3 - 5 position alpha-numeric codes beginning with W,
X, Y or Z
- Note: XX000 as a diagnosis = a laboratory service
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Examples of Level 1 HCPCS or CPT codes
00100 -01999 Anesthesia
10040 - 69990 Surgery
70010 - 79999 Radiology
80049 - 89399 Pathology and Laboratory
90281 - 99199 Medicine
99201 - 99499 Evaluation and Management
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HCPCS – Issues for researchers (1)
1. What is actually included in a Evaluation and
Management (E&M) visit?
Codes 99201 - 99499
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HCPCS - Examples of level 2 codes
A0000 - A0999 Transportation Services including
Ambulance
A4000 - A8999 Medical and Surgical Supplies
A9000 - A9999 Administrative, Miscellaneous and
Investigational
B4000 - B9999 Enteral and parenteral therapy
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HCPCS - More examples of level 2
A4253 - Blood Glucose or reagent strips for home
blood glucose monitoring- per 50
A4259 - Lancets -box of 100
A2000 - Manipulation of spine by chiropractor
A0344 - Ambulance services, ALS, non-
emergency, no specialized ALS
plus ---- lots of other ambulance
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HCPCS - examples of level 1 & level 2 preventive services codes
Preventive services
- Influenza vaccine 90654, 90656 or 90658*
- Influenza vaccine administration G0008
- Pneumococcal polysac. vaccine 90732
- Pneumococcal vaccine administration G0009
- Fecal occult blood test G0238 or G0107
- Flexible sigmoidoscopy G0104
- Colonoscopy G0105
* Note: In 2011, discontinue 90656 and use Q2035 – Q2039
for split-virus vaccine….. pay attention. Things keep changing .
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Changes in HCPCS
Level 1 and Level 2 HCPCS may change annually
Level 3 HCPCS may change more frequently
CMS is making an effort to eliminate Level 3
HCPCS
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HCPCS - Level 3 codes
Repeat definition : 5 position alpha-numeric codes
beginning with W, X, Y or Z
Source = the MACs (Medicare Administrative
Contractors
CMS is really planning to eliminate
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HCPCS Modifiers
2 Position codes
Level 1 - numeric
- e.g., 21 - Prolonged Evaluation and Management
Services
- 26 - Professional Component
Level 2 - alpha or alpha-numeric
- TC - Technical Component
- LT = left, RT = right
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HCPCS Modifiers
Level 3 – formerly from Carriers, now from MACs
HCPCS modifiers may also change in the course of
a study, but much less likely
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More useful variables in the Line File portion of the Carrier File
Approximately 10,000 HCPCS codes
What’s a poor researcher to do?
HCPCS Line NCH BETOS Code
Useful for Aggregating
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BETOS codes – line NCH BETOS code
M1A = Office visits - new
M1B = Office visits - established
M2A = Hospital visit - initial
M2B = Hospital visit - subsequent
M2C = Hospital visit - critical care
M3 = Emergency room visit
M4A = Home visit
M4B = Nursing home visit
M5A = Specialist - pathology
M5B = Specialist - psychiatry
M5C = Specialist - opthamology
M5D = Specialist - other
M6 = Consultations
P0 = Anesthesia
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Physician services and amount Medicare paid for them by, BETOS code
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BETOS Code Services Amount Paid
M1A = Office visits - new 12,063,567 $729,435,905
M1B = Office visits - estab 175,981,446 $5,854,022,879
M2A = Hospital visit - initial 9,084,444 $915,516,580
M2B = Hospital visit - subs 82,434,957 $3,572,740,464
M2C = Hospital visit - critical care2,616,542 $302,633,080
M3 = Emergency room visit 15,135,564 $1,061,258,401
M4A = Home visit 1,531,304 $97,078,383
M4B = Nursing home visit 19,766,584 $720,985,090
M5A = Specialist - pathology 16,926,656 $673,411,742
M5B = Specialist - psychiatry 17,229,471 $654,250,877
M5C = Specialist - opthamology 21,782,022 $1,007,691,689
M5D = Specialist - other 9,641,201 $127,907,388
More useful variables in the Line File portion of the Carrier File
Line Allowed Charge Amount - the charges allowed
by CMS
Line NCH Payment Amount - the amount paid by
CMS
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Relationship between line allowed charge amount and line NCH payment amount
NCH Payment Amount generally 80% of Line NCH
Allowed Charge Amount. WHY?
For laboratory services the two values are the
same. WHY?
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More useful variables in the Line File portion of the Carrier File
Don’t over count the count.
- Carrier Line Miles/Time/Units/Services (MTUS) count
- Carrier Line Miles/Time/Units/Services indicator code
- Did the beneficiary use 40 ambulances?
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MTUS Indicator Code Values
0 = Values reported as zero (no allowed activities)
1 = Transportation (ambulance) miles
2 = Anesthesia time units
3 = Services
4 = Oxygen units
5 = Units of blood
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More useful variables in the Line File portion of the Carrier File
Information about the provider of service:
- Carrier Line Performing PIN Number
- Carrier Line Performing UPIN Number
- Line CMS Provider Specialty Code
- Carrier Line Performing NPI (National Provider
Identification Number)
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Provider of service information
The provider had to submit a PIN (Provider
Identification Number) on the CMS 1500 claim
The Carrier picked a UPIN (Unique Physician
Identification Number) for that PIN
CMS added the Provider Specialty based on the
UPIN
PIN, UPIN, AND PROVIDER SPECIALTY – THE OLD STORY
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National Provider Identification Number – NPI - and its implementation
In 2006 CMS started requiring the use NPI for providers in in billing using the CMS 1500 form
Electronic submission of claims - Through 1/2/ 06 – NPI not accepted
- 2/3/06 – 10/1/06 – NPI accepted, but only if UPIN is also reported
- 10/2/06 – 5/22/07 – NPI or UPIN accepted; encourage both to speed payment
- 5/23/07 and after – NPI must be submitted; No UPIN
Paper submission of claims - All of 2006 NPI not accepted; no place on claim
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NPI and UPIN use in 2006
Percent of Physician-related Carrier Line Items with
NPI and/or UPIN in 2006
All of 2006 After October 1st
NPI only 0.02 0.05
UPIN only 97.05 92.72
Both 1.65 5.53
Neither 1.28 1.81
MINIMAL IMPACT OF NPI
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Percent of physician-related Carrier line items with NPI and/or UPIN July through
Dec., 2007
Neither 0.42
UPIN only 12.35
NPI only 5.30
Both NPI and UPIN 81.93
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NPI implementation – Summary of the new story
Minimal impact on the 2006 data files, but major
conversion by second half of 2007. Still need to
work with UPINs for those 2 years.
2008 and 2009 only have NPI.
Use the TAX_NUM variable which has replaced the
PIN to identify the entity that is paid for the Part B
service.
Specialty code now derived by CMS from NPI.
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Line CMS Provider Specialty Codes
01 = General practice
02 = General surgery
03 = Allergy/immunology
04 = Otolaryngology
05 = Anesthesiology
06 = Cardiology
07 = Dermatology
08 = Family practice
09 = Gynecology (osteopaths only)(discontinued 5/92 use code 16)
10 = Gastroenterology
11 = Internal medicine
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More line CMS provider specialty codes
40 = Hand surgery
41 = Optometry (revised 10/93 to mean optometrist)
42 = Certified nurse midwife (eff 1/87)
43 = CRNA, anesthesia assistant (eff 1/87)
44 = Infectious disease
45 = Mammography screening center
46 = Endocrinology (eff 5/92)
47 = Independent Diagnostic Testing Facility (IDTF) (eff. 6/98)
48 = Podiatry
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Examples of uses of the Carrier File
Counting services provided by physicians and
others
Identifying cohorts of persons with chronic
diseases (Next presentation)
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Counting services provided by physicians and other Part B providers
Example: Mammography
How many women received a mammogram in 200X? Example is pre-2007.
How do you define mammography – all??; DX??; screening?? What HCPCS codes do you use?
Why use the Carrier file?
Would you need to use additional files? Any additional codes?
Do you want to count mammograms, or women tested?
What are you worried about in getting an accurate count?
- Too few???, or Too many???
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Mammography HCPCS pre-2007
- Mammography - unilateral 76090
- Mammography - bilateral 76091
- Mammography - screening 76092
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Claims for Mammogram, by Type of Mammogram, Female Medicare Beneficiaries, 1999-2001
(RESIDENTS OF SEER AREAS WITHOUT BREAST CANCER)
Type of
Type of
Mammogram Carrier File Outpatient Carrier + Carrier or Overcount Undercount
File Outpatient Outpatient using both Carrier only
Unilateral - Dx 2,279 1,388 3,667 2,474 1,388
Bilateral - Dx 6,578 3,282 9,860 7,444 3,282
Screening 18,237 10,204 28,441 19,190 10,204
Total claims 27,094 14,874 41,968 29,108 14,874
Total persons 25,359 13,994 39,353 26,112 13,241 753
Source of Data
Number of Claims(Black) or Persons (Red)
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Claims for Mammogram, Female Medicare Beneficiaries, 1999-2001
(Residents of SEER Areas without breast cancer)
Type of
Mammogram Carrier File Outpatient Carrier + Carrier or Overcount Undercount
File Outpatient Outpatient using both Carrier only
Unilateral - Dx
Bilateral - Dx
Screening
Total claims 27,094 14,874 41,968 29,108 14,874
Total persons 25,359 13,994 39,353 26,112 13,241 753
Number of Claims or Persons
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Claims for Mammogram, female Medicare beneficiaries, 1999-2001
(Residents of SEER areas without cancer)
Type of
Mammogram Overcount % Overcount Undercount % of Total if
counting both Carrier only used Carrier only
Unilateral - Dx
Bilateral - Dx
Screening
Total claims 14,874 0.35
Total persons 13,241 50.7 753 0.97
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Using 5% or 100% Carrier File
5% sample verses 100%
You cannot receive 100% national Carrier File
But you may need the 100% Carrier File to have enough power to study smaller geographic areas
May have 100% selected by demographics, diagnoses, procedures, etc. Barb will talk about tomorrow.
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