Variable: CLM_PRCR_RTRN_CD
Claim Pricer Return Code
Description
The code used to identify various prospective payment system (PPS) payment adjustment types. This code identifies the payment return code or the error return code for every claim type calculated by the PRICER tool.
Comment
The payment return code identifies the type of payment calculated by the PRICER software.
Values
This variable is coded, and will contain one of the following values.
| Value | Description |
|---|---|
| 00 | Paid normal DRG payment |
| 01 | Paid as a day outlier (Note: day outlier no longer being paid as of 10/1/97) |
| 02 | Paid as a cost outlier |
| 03 | Transfer paid on a per diem basis up to and including the full DRG |
| 05 | Transfer paid on a per diem basis up to and including the full DRG which also qualified for a cost outlier payment |
| 06 | Provider refused cost outlier |
| 10 | DRG is 209, 210, or 211 and post-acute transfer |
| 12 | Post-acute transfer with specific DRGs. The following DRG's: 14, 113, 236, 263, 264, 429, 483 |
| 14 | Paid normal DRG payment with per diem days = or > GM ALOS |
| 16 | Paid as a cost outlier with per diem days = or > GM ALOS Inpatient Hospital Error return codes: |
| 51 | No provider specific information found |
| 52 | Invalid MSA# in provider file |
| 53 | Waiver state - not calculated by PPS |
| 54 | DRG < 001 or > 511, or = 214, 215, 221, 222, 438, 456, 457, 458 |
| 55 | Discharge date < provider effective start date or discharge date < MSA effective start date for PPS |
| 56 | Invalid length of stay |
| 57 | Review code invalid (Not 00, 03, 06, 07, 09) |
| 58 | Total charges not numeric |
| 61 | Lifetime reserve days not numeric or BILL-LTR-DAYS > 60 |
| 62 | Invalid number of covered days |
| 65 | PAY-CODE not = A, B or C on provider specific file for capital |
| 67 | Cost outlier with LOS > covered days ***Inpatient Rehab Facility (IRF) Pricer Return Codes*** IRF Payment return codes: |
| 00 | Paid normal CMG payment without outlier |
| 01 | Paid normal CMG payment with outlier |
| 02 | Transfer paid on a per diem basis without outlier |
| 03 | Transfer paid on a per diem basis with outlier |
| 04 | Blended CMG payment -- 2/3 Federal PPS rate + 1/3 provider specific rate --without outlier |
| 05 | Blended CMG payment -- 2/3 Federal PPS rate + 1/3 provider specific rate -- with outlier |
| 06 | Blended transfer payment -- 2/3 Federal PPS transfer rate + 1/3 provider specific rate -- without outlier |
| 07 | Blended transfer payment -- 2/3 Federal PPS transfer rate + 1/3 provider specific rate -- with outlier |
| 10 | Paid normal CMG payment with penalty without outlier |
| 11 | Paid normal CMG payment with penalty with outlier |
| 12 | Transfer paid on a per diem basis with penalty without outlier |
| 13 | Transfer paid on a per diem basis with penalty with outlier |
| 14 | Blended CMG payment -- 2/3 Federal PPS rate + 1/3 provider specific rate -- with penalty without outlier |
| 15 | Blended CMG payment -- 2/3 Federal PPS rate + 1/3 provider specific rate -- with penalty with outlier |
| 16 | Blended transfer payment -- 2/3 Federal PPS transfer rate + 1/3 provider specific rate -- with penalty without outlier |
| 17 | Blended transfer payment -- 2/3 Federal PPS transfer rate + 1/3 provider specific rate -- with penalty with outlier IRF Error return codes: |
| 50 | Provider specific rate not numeric |
| 51 | Provider record terminated |
| 52 | Invalid wage index |
| 53 | Waiver state - not calculated by PPS |
| 54 | CMG on claim not found in table |
| 55 | Discharge date < provider effective start date or discharge date < MSA effective start date for PPS |
| 56 | Invalid length of stay |
| 57 | Provider specific rate zero when blended payment requested |
| 58 | Total covered charges not numeric |
| 59 | Provider specific record not found |
| 60 | MSA wage index record not found |
| 61 | Lifetime reserve days not numeric or BILL-LTR-DAYS > 60 |
| 62 | Invalid number of covered days |
| 65 | Operating cost-to-charge ratio not numeric |
| 67 | Cost outlier with LOS > covered days or cost outlier threshold calculation |
| 72 | Invalid blend indicator (not 3 or 4) |
| 73 | Discharged before provider FY begin date |
| 74 | Provider FY begin date not in 2002 ***Long Term Care Hospital (LTCH) Pricer Return Codes*** LTCH Payment return codes: |
| 00 | Normal DRG payment without outlier |
| 01 | Normal DRG payment with outlier |
| 02 | Short stay payment without outlier |
| 03 | Short stay payment with outlier |
| 04 | Blend year 1 - 80% facility rate plus 20% normal DRG payment without outlier |
| 05 | Blend year 1 - 80% facility rate plus 20% normal DRG payment with outlier |
| 06 | Blend year 1 - 80% facility rate plus 20% short stay payment without outlier |
| 07 | Blend year 1 - 80% facility rate plus 20% short stay payment with outlier |
| 08 | Blend year 2 - 60% facility rate plus 40% normal DRG payment without outlier |
| 09 | Blend year 2 - 60% facility rate plus 40% normal DRG payment with outlier |
| 10 | Blend year 2 - 60% facility rate plus 40% short stay payment without outlier |
| 11 | Blend year 2 - 60% facility rate plus 40% short stay payment with outlier |
| 12 | Blend year 3 - 40% facility rate plus 60% normal DRG payment without outlier |
| 13 | Blend year 3 - 40% facility rate plus 60% normal DRG payment with outlier |
| 14 | Blend year 3 - 40% facility rate plus 60% short stay payment without outlier |
| 15 | Blend year 3 - 40% facility rate plus 60% short stay payment with outlier |
| 16 | Blend year 4 - 20% facility rate plus 80% normal DRG payment without outlier |
| 17 | Blend year 4 - 20% facility rate plus 80% normal DRG payment with outlier |
| 18 | Blend year 4 - 20% facility rate plus 80% short stay payment without outlier |
| 19 | Blend year 4 - 20% facility rate plus 80% short stay payment with outlier LTCH Error return codes: |
| 50 | Provider specific rate not numeric |
| 51 | Provider record terminated |
| 52 | Invalid wage index |
| 53 | Waiver state - not calculated by PPS |
| 54 | DRG on claim not found in table |
| 55 | Discharge date < provider effective start date or discharge date < MSA effective start date for PPS |
| 56 | Invalid length of stay |
| 57 | Provider specific rate zero when blended payment requested |
| 58 | Total covered charges not numeric |
| 59 | Provider specific record not found |
| 60 | MSA wage index record not found |
| 61 | Lifetime reserve days not numeric or BILL-LTR-DAYS > 60 |
| 62 | Invalid number of covered days |
| 65 | Operating cost-to-charge ratio not numeric |
| 67 | Cost outlier with LOS > covered days or cost outlier threshold calculation |
| 72 | Invalid blend indicator (not 1 thru 5) |
| 73 | Discharged before provider FY begin date |
| 74 | Provider FY begin date not in 2002 *************SNF Pricer Return Codes********* *******************TOB 21X******************* SNF Payment return codes: |
| 00 | RUG III group rate returned SNF Error return codes: |
| 20 | Bad RUG code |
| 30 | Bad MSA code |
| 40 | Thru date < July 1, 1998 or invalid |
| 50 | Invalid Federal blend for that year |
| 60 | Invalid Federal blend |
| 61 | Federal blend = 0 and SNF thru date < January 1, 2000 *********Hospice Pricer Return Codes************ **************TOB 81X or 82X******************** Hospice Payment Return Codes: |
| 00 | Home rate returned Hospice Error Return Codes: |
| 10 | Bad units |
| 20 | Bad units2 < 8 |
| 30 | Bad MSA code |
| 40 | Bad hospice wage index from MSA file |
| 50 | Bad bene wage index from MSA file |
| 51 | Bad provider number *******Home Health Pricer Return Codes************ *****TOB 32X or 33X, DOS 10/1/2000 and after****** Home Health Payment Return Codes: |
| 00 | Final payment where no outlier applies |
| 01 | Final payment where outlier applies |
| 03 | Initial percentage payment, 0% |
| 04 | Initial percentage payment, 50% |
| 05 | Initial percentage payment, 60% |
| 06 | LUPA payment only |
| 07 | Final payment, SCIC |
| 08 | Final payment, SCIC with outlier |
| 09 | Final payment, PEP |
| 11 | Final payment, PEP with outlier |
| 12 | Final payment, SCIC within PEP |
| 13 | Final payment, SCIS within PEP with outlier Home Health Error Return Codes: |
| 10 | Invalid TOB |
| 15 | Invalid PEP Days |
| 16 | Invalid HRG Days, >60 |
| 20 | PEP indicator invalid |
| 25 | Med review indicator invalid |
| 30 | Invalid MSA code |
| 35 | Invalid Initial Payment Indicator |
| 40 | Dates < October 1, 2000 or invalid |
| 70 | Invalid HRG Code |
| 75 | No HRG present in 1st occurrence |
| 80 | Invalid Revenue code |
| 85 | No revenue code present on HH final claim/adjustment ************Outpatient PPS Pricer Return Codes****** Outpatient PPS Payment return codes: |
| 01 | Line processed to payment |
| 20 | Line processed but payment = 0 bene deductible = > adjusted payment Outpatient PPS Error return codes: |
| 30 | Missing, deleted or invalid APC |
| 38 | Missing or invalid discount factor |
| 40 | Invalid service indicator passed by the OCE |
| 41 | Service indicator invalid for OPPS PRICER |
| 42 | APC = '00000' or (packaging flag = 1 or 2) |
| 43 | Payment indicator not = to 1 or 5 thru 9 |
| 44 | Service indicator = 'H' but payment indicator not = to 6 |
| 45 | Packaging flag not = to 0 |
| 46 | Line item denial/reject flag not = to 0 or line item denial/reject flag = to 1 and (APC |
| not | 0033 or 0034 or 0322 or 0323 or 0324 or 0325 or 0373 or 0374)) or line item action flag not = to 1 |
| 47 | Line item action flag = 2 or 3 |
| 48 | Payment adjustment flag not valid |
| 49 | Site of service flag not = to 0 or (APC 0033 is not on the claim and service indicator = 'P' or APC = 0322, 0325, 0373, 0374) |
| 50 | Wage index not located |
| 51 | Wage index equals zero |
| 52 | Provider specific file wage index reclassification code invalid or missing |
| 53 | Service from date not numeric or < 20000801 |
| 54 | Service from date < provider effective date or service from date > provider termination date ***End Stage Renal Disease (ESRD) Pricer Return Codes*** ESRD Payment return codes: |
| 00 | ESRD PPS payment calculated |
| 01 | ESRD facility rate > zero ESRD Error return codes: |
| 50 | ESRD facility rate not numeric |
| 52 | Provider type not = '40' or '41' |
| 53 | Special payment indicator not = '1' or blank |
| 54 | Date of birth not numeric or = zero |
| 55 | Patient weight not numeric or = zero |
| 56 | Patient height not numeric or = zero |
| 57 | Revenue center code not in range |
| 58 | Condition code not = '73' or '74' or blank |
| 60 | MSA wage adjusted rate record not found |
| 98 | Claim through date before 4/1/2005 or not numeric |
Other Info
Some additional information on this variable:
- Short Name: CLM_PRCR_RTRN_CD
- Long Name: CLM_PRCR_RTRN_CD
- Type: CHAR
- Length: 2
- Source: NCH
- Value Format: