Provider-Specific File

F. Inpatient Rehabilitation Facilities (IRFs) 

The A/B MACs (A) create a provider specific history file using the following data elements for each IRF beginning with their first cost reporting period that starts on or after January 1, 2002. A/B MACs (A) submit the current and the preceding fiscal years every three months. For PPS-exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file. Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 18, 19, 21, 25, 27, 28, and 42 are required. All other data elements are optional for this provider type. 

Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required. Data element 35 is required for all IRFs. Data elements 17, 33, 38, and 49 are required if applicable to the IRF. 

Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.

G. Long Term Care Hospital (LTCH) 

The A/B MACs (A) create a provider specific history file using the following data elements for each LTCH beginning with their first cost reporting period that starts on or after October 1, 2002. A/B MACs (A) submit the current and the preceding fiscal years every three months. For PPS-exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file. Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 18, 19, 21, 22, and 25 are the minimum required fields for entering a provider under LTCH PPS. 

Effective July 1, 2005, data element 35 is required. Data elements 33 and 38 are optional and may be populated if needed. Data elements 12, 13, and 14 are no longer applicable. 

Effective July 1, 2006, data elements 23, 24, 27, 28, and 49 are required. 

Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.

H. Inpatient Psychiatric Facilities (IPF)

The A/B MACs (A) create a provider specific history file using the following data elements for each IPF beginning with their first cost reporting period that starts on or after January 1, 2005.

The A/B MACs (A) submit the current and the preceding fiscal years every three months. For PPS-exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file. Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 13, 17, 18, 19, 21, 22, 23, 25, 33, 35, 38, and 48 are required. All other data elements are optional for this provider type. Although data element 25 refers to the operating cost to charge ratio, ensure that both operating and capital cost-to-charge ratio are entered in data element 25 for IPFs. Ensure that data element 21 (Facility Specific Rate) will be determined using the same methodology to determine the interim payment per discharge under the TEFRA system.

 Effective July 1, 2006, data element 13 is no longer required. Data elements 33 and 38 are optional and may be populated if needed. 

Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.

Medicare Claims

A. PPS 

Hospitals The A/B MACs (A) submit all records (past and current) for all PPS providers every three months. Duplicate the provider file used in the "PRICER" module of the claims processing system.

 B. Non-PPS Hospitals and Exempt Units 

The A/B MACs (A) create a provider specific history file using the listed data elements for each non-PPS hospital and exempt hospital unit. Submit the current and the preceding fiscal years every three months. Code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file. 

C. Hospice 

The A/B MACs (A) create a provider specific history file using the following data elements for each hospice. Submit the current and the preceding fiscal years every three months. Data elements 3, 4, 5, 6, 9, 10, 13, and 17 are required. All other data elements are optional for this provider type. 

Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required. Data element 35 is required for all hospices. Data elements 33 and 38 are optional and may be populated if needed. 

Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.

D. Skilled Nursing Facility (SNF) 

The A/B MACs (A) create a provider specific history file using the following data elements for each SNF beginning with their first cost reporting period that starts on or after July 1, 1998. 

The A/B MACs (A) submit the current and the preceding fiscal years every three months. For PPS-exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file. Data elements 3, 4, 5, 6, 9, 10, 13, 19, and 21 are required. All other data elements are optional for this provider type. 

Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required. Data element 35 is required for all SNFs. Data elements 33 and 38 are required if there is a special wage index. Effective October 1, 2005, through September 30, 2006, data elements 33 and 38 are required since there is a special wage index.

E. Home Health Agency (HHA) 

The A/B MACs (HHH) create a provider specific history file using the following data elements for each HHA. Regional home health A/B MACs (HHH) submit the current and the preceding fiscal years every three months. Data elements 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, and 19 are required. All other data elements are optional for this provider type. All fields must be zero filled if not completed. Update the effective date in data element 4 annually. Ensure that the current census division in data element 11 is not zero. Ensure that the waiver indicator in data element 8 is N. Ensure that the MSA code reported in data element 13 is a valid MSA code.

Provider-Specific File

(Rev. 3431, Issued: 12-29-15, Effective: 10-01-15, Implementation: 10-05-15)

The PROV file contains needed information about each provider to enable the pricing software to calculate the payment amount. Updates are published annually or quarterly, as needed, to notify A/B MACs of any changes to payment systems requiring updates to the PSF. 

The A/B MACs maintain the accuracy of the data in accordance with the following criteria. 

Whenever the status of any element changes, the A/B MAC prepares an additional record showing the effective date. For example, when a hospital's FY beginning date changes as a result of a change in ownership or other "good cause," the A/B MAC makes an additional record showing the effective date of the change. 

The format and data required by the PRICER program and by the provider-specific file is found in Addendum A.

The A/B MACs submit a file of provider-specific payment data to CMS CO every three months for PPS and non-PPS hospitals, inpatient rehabilitation hospitals or units (referred to as IRFs), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs), SNFs, and hospices, including those in Maryland. Regional home health A/B MACs (HH) submit a file of provider specific data for all home health agencies. A/B MACs serving as the audit A/B MAC for hospital based HHAs do not submit a file of provider specific data for HHAs. 

The A/B MACs create a new record any time a change occurs for a provider. Data must be reported for the following periods: October 2 - January 1, January 2 - April 1, April 2 - July 1, and July 2 - October 1. This file must be received in CO within seven business days after the end of the period being reported. 

NOTE: A/B MACs submit the latest available provider-specific data for the entire reporting period to CO by the seven-business day deadline. If CO fails to issue applicable instructions concerning changes or additions to the file fields by 10 calendar days before the end of the reporting period, the A/B MAC may delay reporting of data related to the CO instructions until the next file due date. For example, if CO instructions changing a file field are issued on or after September 21 with an effective date of October 1, the A/B MAC may exclude the October 1 CO-required changes from the file submitted by October 9. The A/B MAC includes the October 1 CO-required changes, and all subsequent changes through January 1 in the file submitted in January.

PPS Pricer Program

(Rev. 1, 10-01-03) A3-3615.3, A3-3656.3

The CMS provides a Pricer program to determine the price upon which to base payment under prospective payment. A separate Pricer installation guide is provided. The A/B MAC (A) uses the Pricer appropriate for the date of discharge. 

After GROUPER determines the DRG, the A/B MAC (A) 's system calls the Pricer program. Pricer determines the price to pay and prepares a report. 

Four data files are included. CMS maintains three: 

• DRGX file - contains DRG weights, average length of stay and outlier cutoff points. 

• MSAX file - contains urban and rural wage indexes used in calculating payment. CMS may request that the A/B MAC (A) make interim changes to this file when index changes are issued for individual hospitals after issuance of Pricer for the period. 

• RATE file - contains census division values and updating amounts used in calculating payment.

The A/B MAC (A) maintains the provider-specific file, (PROV file). This contains information about the facts specific to the provider that affect computations, e.g., effective dates for PPS, type of provider (for application of special computation rules), census division, MSA, adjusted cost per discharge, disproportionate share adjustment percentage, and capital data. 

Pricer also calculates the disproportionate share adjustment and adds it to the DRG payment. Correct calculation depends upon the accuracy of related information the A/B MAC (A) includes in the PRICER PROV file. 

The Pricer program applies the DRG relative weights, hospital urban or rural and census division location, provider-specific data, and beneficiary hospital data from the bill to determine the amount payable for each PPS discharge bill. 

Pricer uses the Intern-to-Bed ratio in calculating the indirect teaching adjustment for operating costs for the A/B MAC (A) to accumulate and use in related payments. Pricer uses the intern-to-average daily census ratio to calculate the indirect teaching adjustment for capital costs. The A/B MAC (A) ensures that these ratios are available for Pricer to compute payment for teaching hospitals. It includes the ratios in its PROV file to ensure that cost outliers are not overpaid to its teaching hospitals. 

Pricer does not calculate utilization days required for the PS&R, CWF, or cost report. It does not determine the amount to pay after deduction for deductible, coinsurance, or the primary payment where Medicare is secondary. The A/B MAC (A) must calculate the price and make adjustments to the price furnished before making payment 

The A/B MACs (A) use the Pricer implementation guide for information concerning Pricer processing reports, input parameters and data requirements.

DRG GROUPER Program

(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD- 10, ASC X12: September, 23 2014)

The A/B MAC (A) pays for inpatient hospital services on the basis of a rate per discharge that varies according to the MS-DRG to which a beneficiary's stay is assigned. Each MSDRG represents the average resources required to care for a case in that particular MSDRG relative to the national average of resources consumed per case. The MS-DRG weights used to calculate payment are in the Pricer DRGX file. 

The A/B MAC (A) uses the GROUPER program to assign the MS-DRG number. GROUPER determines the MS-DRG from data elements reported by the hospital. This applies to all inpatient discharge/transfer bills received from both PPS and non-PPS facilities, including those from waiver States, long-term care hospitals, and excluded units. T

he Pricer (PPSMAIN) driver program calls the correct fiscal year GROUPER based upon the discharge date. If the A/B MAC (A) or shared system writes its own driver program, it must access the GROUPER for the correct FY based on discharge date. GROUPER does not determine the MS-DRG price. GROUPER input/output are specified below. The A/B MAC (A) determines the best place in its total system to place the GROUPER program.

Grouper requires the following items:

1. Principal and up to 24 other diagnoses 

2. Principal and up to 24 additional procedures 

3. Age at last birthday at admission 

4. Sex (1=male and 2=female) 

5. Discharge destination (patient status code from the claim)

The claim sex coding is M for male and F for female while GROUPER is l for male and 2 for female. Discharge destination codes are similar to claim definitions for patient status except codes 20-29 are summarized as 20. The A/B MAC (A) calculates age at admission. GROUPER needs age rather than date of birth.

Grouper responds with the following information: 

1. Major diagnostic category 

2. MS-DRG number 

3. Grouper return code (a one position code indicating the action taken by the program) 

4. Procedure code used in determining the MS-DRG 

5. Diagnosis code used in determining the MS-DRG 

6. Secondary diagnosis code used in determining the MS-DRG, if applicable

Paying Claims Outside of the MCE

All institutional inpatient claims are routed through the MCE before they are processed to payment. There may be special circumstances, however, when it is necessary to pay claims bypassing MCE edits. The CMS will notify the contractor of these instances. They include:

• New coverage policies are enacted by Congress with effective dates that preclude making the necessary changes timely; and 

• Errors are discovered that cannot be corrected timely. 

A/B MACs (A) are responsible for reporting problems timely. 

Requesting to Pay Claims Without MCE Approval

The contractor may also request approval from the RO in specific situations to pay claims without first sending them through the MCE. 

Examples of such situations are: 

• A systems error cannot be corrected timely, and the provider's cash flow will be substantially impacted; and/or 

• Administrative Law Judge (ALJ) decisions, court decisions, and CMS instructions in particular cases may necessitate that payment be made outside the normal process.

Procedures for Paying Claims Without Passing through the MCE (Rev. 2117, Issued: 12-10-10, Effective: 01-12-11, Implementation: 01-12-11)

Before an inpatient claim may be paid without first going through the MCE, the contractor shall obtain approval from CMS Central Office or the RO. 

Note: In certain situations, contractors bypass the MCE through an established, CMSinstructed claim processing procedure (e.g., to verify a facility is certified to perform a specified service after a MCE limited coverage edit is applied). Such scenarios do not require approval from the RO as the approval for such a bypass was inherently implied when the established procedure was first implemented.

 In all instances involving payment outside the normal inpatient editing process, the contractor applies the following procedures: 

• Contractors shall submit the claim overriding the MCE using the appropriate field in FISS. 

• Pay interest accrued through the date payment is made on clean claims. Do not pay any additional interest. 

• Maintain a record of payment and implement controls to be sure that incorrect payment is not made, i.e., when the claim is paid without being subject to normal editing. 

• Monitor MCE software to determine when the impediment to processing is removed. 

• Consider the claim processed for workload and expenditure reports when it is paid.

• Submit to the RO Consortium Contractor Manager (CCM) by the 20th of each month a report of all inpatient claims paid without processing through the MCE with the exception of override situations explained in the Note above (e.g., for limited coverage edits). The list of claims paid outside of the MCE is to include the following information:

o HIC 

o DCN 

o TOB

o DOS (From/Through) 

o Provider Number 

o MCE/OCE OVR (Claim/Line)

o Reimbursement Amount 

o Receipt Date 

o Process Date 

o Paid Date

Also, include summary data for each edit code showing claim volume and payment. Any override approvals received and/or relevant JSM references should be annotated on the reports.

Processing Requirements

13. Bilateral Procedure 

There are codes that do not accurately reflect performed procedures in one admission on two or more different bilateral joints of the lower extremities. A combination of these codes show a bilateral procedure when, in fact, they could be single joint procedures (i.e., duplicate procedures). 

If two more of these procedures are coded, and the principal diagnosis is in MDC 8, the claim is flagged for post-pay development. The A/B MAC (A) processes the bill as coded but requests an O.R. report. If the report substantiates bilateral surgery, no further action is necessary. If the O.R. report does not substantiate bilateral surgery, an adjustment bill is processed. 

If the error rate for any provider is sufficiently high, the A/B MAC (A) may develop claims prior to payment on a provider-specific basis. 

Effective with the implementation of ICD-10, ICD-10-PCS codes will be implemented which clearly identify the exact joint (left or right). Reporting these two more precise ICD-10-PCS codes will clearly indicate if a bilateral procedure is performed.

14. Invalid Age 

If the hospital reports an age over l24, the A/B MAC (A) requests the hospital to determine if it made a bill preparation error. If the beneficiary's age is established at over l24, the hospital enters 123. 

15. Invalid Sex 

A patient's sex is sometimes necessary for appropriate MS-DRG determination. Usually the A/B MAC (A) can resolve the issue without hospital assistance. The sex code reported must be either 1 (male) or 2 (female). 

16. Invalid Discharge Status 

A patient's discharge status is sometimes necessary for appropriate MS-DRG determination. Discharge status must be coded according to the Form CMS-1450 conventions.

 17. Invalid Discharge Date 

An invalid discharge date is a discharge date that does not fall into the acceptable range of numbers to represent, either the month, day or year (e.g., 13/03/01, 12/32/01). If no discharge date is entered, it is also invalid. MCE reports when an invalid discharge date is entered. 

18. Limited Coverage 

Effective October 1, 2003, for certain procedures whose medical complexity and serious nature incur extraordinary associated costs, Medicare limits coverage. The edit message indicates the type of limited coverage (e.g., LVRS, heart transplant, etc). The procedures receiving limited coverage edits previously were listed as non-covered procedures, but were covered under Medicare in certain circumstances. The A/B MACs (A) will handle these procedures as they had previously. 

19. Procedure inconsistent with length of stay 

The following procedure code should only be coded on claims when the respiratory ventilation is provided for greater than four consecutive days during the length of stay. Effective October 1, 2012, ICD-9-CM procedure code, 96.72, Continuous invasive mechanical ventilation for 96 consecutive hours or more Effective October 1, 2015, ICD-10-PCS code, 5A1955Z - Respiratory Ventilation, Greater than 96 Consecutive Hours

Processing Requirements

9. Unacceptable Principal Diagnosis 

There are selected codes that describe a circumstance which influences an individual's health status but is not a current illness or injury; therefore, they are unacceptable as a principal diagnosis. For example, the diagnosis code for family history of a certain disease would be an unacceptable principal diagnosis since the patient may not have the disease. In a few cases, there are codes that are acceptable if a secondary diagnosis is coded. If no secondary diagnosis is present for them, MCE returns the message "requires secondary dx." The A/B MAC (A) may review claims with specific codes in the Unacceptable Principal Diagnosis section and a secondary diagnosis. A/B MACs (A) may choose to review as a principal diagnosis if data analysis deems it a priority. If these codes are identified without a secondary diagnosis, the A/B MAC (A) returns the bill to the hospital and requests a secondary diagnosis that describes the origin of the impairment. Also, bills containing other "unacceptable principal diagnosis" codes are returned. The hospital reviews the medical record and/or face sheet and enters the principal diagnosis that describes the illness or injury before returning the bill. 

10. Nonspecific O.R. Procedures 

Effective October 1, 2007 (FY 2008), the non-specific O.R. procedure edit was discontinued and will appear for claims processed using MCE version 2.0-23.0 only. 

11. Noncovered O.R. Procedures 

There are some O.R. procedures for which Medicare does not provide payment. The A/B MAC (A) will return the bill requesting that the non-covered procedure and its associated charges be removed from the covered claim, Type of Bill (TOB) 11X. If the hospital wishes to receive a Medicare denial, etc., the hospital may submit a non-covered claim, TOB 110, with the non-covered procedure/charges. 

12. Open Biopsy Check 

Biopsies can be performed as open (i.e., a body cavity is entered surgically), percutaneously, or endoscopically. The MS-DRG Grouper logic assign a patient to different MS-DRGs depending upon whether or not the biopsy was open. In general, for most organ systems, open biopsies are performed infrequently. 

Effective October 1, 1987, there are revised biopsy codes that distinguish between open and closed biopsies. To make sure that hospitals are using diagnosis codes correctly, the A/B MAC (A) requests O.R. reports on a sample of 10 percent of claims with open biopsy procedures for review on a post payment basis.

 If the O.R. report reveals that the biopsy was closed (performed percutaneously, endoscopically, etc.) the A/B MAC (A) changes the procedure code on the bill to the closed biopsy code and processes an adjustment bill. Some biopsy codes (3328 and 5634) have two related closed biopsy codes, one for closed endoscopic and for closed percutaneous biopsies. The A/B MAC (A) assigns the appropriate closed biopsy code after reviewing the medical information. 

Effective October 1, 2010, the open biopsy check edit was discontinued and was only used when processing MCE version 2.0 - 26.0. 

Effective with the implementation of ICD-10, ICD-10-PCS codes will be implemented which clearly identify in greater detail the approach used in the biopsy

Processing Requirements - Continued

5. Sex Conflict

The MCE detects inconsistencies between a patient's sex and a diagnosis or procedure on the patient's record. Examples are: 

• Male patient with cervical cancer (diagnosis). 

• Male patient with a hysterectomy (procedure). 

In both instances, the indicated diagnosis or the procedure conflicts with the stated sex of the patient. Therefore, either the patient's diagnosis, procedure or sex is incorrect. 

The MCE contains listings of male and female related diagnosis and procedure codes and the corresponding English descriptions. The hospital should review the medical record and/or face sheet and enter the proper sex, diagnosis, and procedure before returning the bill.

6. Manifestation Code 

As Principal Diagnosis A manifestation code describes the manifestation of an underlying disease, not the disease itself, and therefore, cannot be a principal diagnosis. The MCE contains listings of diagnosis codes identified as manifestation codes. The hospital should review the medical record and/or face sheet and enter the proper diagnosis before returning the bill. 

7. Nonspecific Principal Diagnosis

 Effective October 1, 2007 (FY 2008), the non-specific principal diagnosis edit was discontinued and will appear for claims processed using MCE version 2.0-23.0 only.

8. Questionable Admission

There are some diagnoses which are not usually sufficient justification for admission to an acute care hospital. 

The MCE contains a listing of diagnosis codes identified as "Questionable Admission" when used as principal diagnosis. 

The A/B MACs (A) may review on a post-payment basis all questionable admission cases. Where the A/B MAC (A) determines the denial rate is sufficiently high to warrant, it may review the claim before payment.

Processing Requirements

The hospital must follow the procedure described below for each error code. For bills returned to the provider, the A/B MAC (A) considers the bill improperly completed for control and processing time purposes.

NOTE: The following instructions are based on ICD-9-CM diagnosis and procedure codes. Applicable ICD-10-CM and ICD-10-PCS codes will be provided as part of the annual updates when ICD-10 is implemented. 

1. Invalid Diagnosis or Procedure Code 

The MCE checks each diagnosis code, including the admitting diagnosis, and each procedure code against a table of valid diagnosis and procedure codes. An admitting diagnosis, a principle diagnosis, and up to eight additional diagnoses may be reported. Up to six total procedure codes may be reported on an inpatient claim. If the recorded code is not in this table, the code is invalid, and the A/B MAC (A) returns the bill to the provider. 

For a list of valid diagnosis or procedure codes see the "International Classification of Diseases” revision applicable to the date of the inpatient discharge or other service and the "Addendum/Errata" and new codes furnished by the A/B MAC (A). The hospital must review the medical record and/or face sheet and enter the correct diagnosis/procedure codes before returning the bill.

2. External Cause of Injury Code as Principal Diagnosis 

External Cause of Injury codes describe the circumstances that caused an injury, not the nature of the injury, and therefore are not recognized by the Grouper program as acceptable principal diagnoses. In ICD-9-CM the external cause of injury diagnosis codes begin with the letter E. In ICD-10-CM the external cause of injury codes begin with the letters V, W, X and Y. For a list of all External cause of injury codes, see "International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), January 1979, Volume l (Diseases)" and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The hospital must review the medical record and/or face sheet and enter the correct diagnosis before returning the bill.

3. Duplicate of PDX 

Any secondary diagnosis that is the same code as the principal diagnosis is identified as a duplicate of the principal diagnoses. This is unacceptable because the secondary diagnosis may cause an erroneous assignment to a higher severity MS-DRG. Hospitals may not repeat a diagnosis code. The A/B MAC (A) will delete the duplicate secondary diagnosis and process the bill.

4. Age Conflict

The MCE detects inconsistencies between a patient's age and any diagnosis on the patient's record. Examples are:

 • A 5-year-old patient with benign prostatic hypertrophy. 

• A 78-year-old delivery. 

In the above cases, the diagnosis is clinically impossible in a patient of the stated age. Therefore, either the diagnosis or age is presumed to be incorrect. Four age code categories are described below.

• A subset of diagnoses is intended only for newborns and neonates. These are "Newborn" diagnoses. For "Newborn" diagnoses, the patient's age must be 0 years. 

• Certain diagnoses are considered reasonable only for children between the ages of 0 and 17. These are "Pediatric" diagnoses. 

• Diagnoses identified as "Maternity" are coded only for patients between the ages of l2 and 55 years.

• A subset of diagnoses is considered valid only for patients over the age of 14. These are "Adult" diagnoses. For "Adult" diagnoses the age range is 15 through 124.

Provider specialty code

Nonphysician Practitioner, Supplier, and Provider Specialty Codes

The following list of 2-digit codes and narrative describe the kind of medicine non-physician practitioners or other healthcare providers/suppliers practice.

Code  Non-physician Practitioner/Supplier/Provider Specialty
15       Speech Language Pathologists
32       Anesthesiologist Assistant
42       Certified Nurse Midwife (effective July 1, 1988)
43       Certified Registered Nurse Anesthetist (CRNA)
45       Mammography Screening Center
47       Independent Diagnostic Testing Facility (IDTF)
49      Ambulatory Surgical Center
50      Nurse Practitioner
51      Medical supply company with orthotic personnel certified by an accrediting organization
52      Medical supply company with prosthetic personnel certified by an accrediting organization
53      Medical supply company with prosthetic/orthotic personnel certifiedby an accrediting organization
54      Medical supply company not included in 51, 52, or 53
55      Individual orthotic personnel certified by an accrediting organization
56      Individual prosthetic personnel certified by an accrediting organization
57      Individual prosthetic/orthotic personnel certified by an accrediting organization
58      Medical Supply Company with registered pharmacist
59      Ambulance Service Supplier, e.g., private ambulance companies, funeral homes
60      Public Health or Welfare Agencies (Federal, State, and local)
61      Voluntary Health or Charitable Agencies (e.g., National Cancer Society, National Heart Association, Catholic Charities)
62      Clinical Psychologist (Billing Independently)
63      Portable X-Ray Supplier (Billing Independently)
64      Audiologist (Billing Independently)
65     Physical Therapist in Private Practice
67     Occupational Therapist in Private Practice
68     Clinical Psychologist
69     Clinical Laboratory (Billing Independently)
71     Registered Dietician/Nutrition Professional
73     Mass Immunization Roster Billers (Mass Immunizers have to roster bill assigned claims and can only bill for immunizations)
74     Radiation Therapy Centers
75     Slide Preparation Facilities
80     Licensed Clinical Social Worker
87     All other suppliers, e.g., Drug Stores
88     Unknown Supplier/Provider
89     Certified Clinical Nurse Specialist
95     Available
96     Optician
97     Physician Assistant
A0    Hospital
A1    Skilled Nursing Facility
A2    Intermediate Care Nursing Facility
A3    Nursing Facility, Other
A4    Home Health Agency
A5    Pharmacy
A6    Medical Supply Company with Respiratory Therapist
A7    Department Store
A8    Grocery Store
B2     Pedorthic Personnel
B3     Medical Supply Company with Pedorthic Personnel
B4     Rehabilitation Agency

NOTE: Specialty Code Use for Service in an Independent Laboratory. For services performed in an independent laboratory, show the specialty code of the physician ordering the x-rays and requesting payment. If the independent laboratory requests payment, use type of supplier code "69".

Post41:

Claim submission

How to Submit Claims 

Claims may be filed to the Medicare Part B carrier in one of two ways: 

* Electronic transmission from the physician ’ s office or from a billing service contracting with the physician

* Paper claim (Form CMS-1500) where not prohibited under the mandatory Medicare electronic filing requirements October 16, 2003 and later

Claims may be electronically submitted to Medicare from a physician ’ s office using a computer with software that meets electronic filing requirements. A sender number is issued, and claims are transmitted directly from the

Type of Service Indicators - CMS BOX 24

Type of Service Indicators - CMS BOX 24

The place of service or diagnosis may be considered when determining the appropriate TOS. The descriptors for each of the TOS codes listed in the following table are:

Type of Service Indicators

Physician Specialty Codes to file the claim

Physician Specialty Codes

Code   Physician Specialty
01    General Practice
02   General Surgery
03   Allergy/Immunology
04   Otolaryngology
05   Anesthesiology
06   Cardiology
07   Dermatology
08   Family Practice
09   Interventional Pain Management
10   Gastroenterology
11   Internal Medicine
12   Osteopathic Manipulative Therapy
13   Neurology
14   Neurosurgery

Who is ordering physician and who is referring physician

Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring physician.

The term "physician" when used within the meaning of §1861(r) of the Act and used in connection with performing any function or action refers to:

1. A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs such function or action;

2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such functions and who is acting within the scope of his/her license when performing such functions;