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.

The meaning of the values varies by type of bill (TOB) ****Inpatient Hospital Pricer Return Codes****** ******************TOB 11X*********************** Inpatient Hospital Payment return codes:
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: