The following return codes are calculated by PRICER and passed back to the calling
program. Depending on the type of payment and case, return codes 30, 44, 33, 40 and 42
indicate that an outlier would be paid if the cost-to-charge ratio would rise by 20
percentage points. If a provider(s) (CCR rises by 10 percentage points and) meets the
criteria of reconciliation, the CMS Central Office uses return codes 30, 44, 33, 40 and 42
to determine a smaller pool of claims for reprocessing claims due to outlier reconciliation.
Acute Care
Return Code 00: Paid normal DRG payment.
Return Code 02: Paid normal DRG payment plus a cost outlier.
Return Code 14: Paid normal DRG payment with per diem days equal or greater than
geometric mean length of stay.
Return Code 16: Paid normal DRG payment plus a cost outlier with per diem days equal
to or greater than geometric mean length of stay.
Return Code 30: Paid normal DRG payment and indicates an outlier payment would be
necessary if the CCR would increase by 20 percentage points.
Return Code 44: Paid normal DRG payment with per diem days equal or greater than
geometric mean length of stay and indicates an outlier payment would be necessary if the
CCR would increase by 20 percentage points.
Transfer Cases
Return Code 03: Paid a per diem payment to the transferring IPPS hospital (when the
patient transfers to an IPPS hospital) up to and including the full DRG payment if the
covered days are less than the geometric mean length of stay for the DRG. If covered
days equal or exceed the geometric mean length of stay, the standard payment is
calculated.
Return Code 05: Paid a per diem payment to the transferring IPPS hospital (when the
patient transfers to an IPPS hospital) up to and including the full DRG payment if the
covered days are less than the geometric mean length of stay for the DRG. If covered
days equal or exceed the geometric mean length of stay, the standard payment is
calculated. Also indicates case qualified for a cost outlier payment.
Return Code 06: Paid a per diem payment to the transferring IPPS hospital (when the
patient transfers to an IPPS hospital) up to and including the full DRG payment if the
covered days are less than the geometric mean length of stay for the DRG. If covered
days equal or exceed the geometric mean length of stay, the standard payment is
calculated. Also indicates provider refused cost outlier payment.
Return Code 33: Paid a per diem payment to the transferring IPPS hospital (when the
patient transfers to an IPPS hospital) up to and including the full DRG payment if the
covered days are less than the geometric mean length of stay for the DRG. If covered
days equal or exceed the geometric mean length of stay, the standard payment is
calculated. Also indicates an outlier payment would be necessary if the CCR increased by
20 percentage points.
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