A Comparison of Medicare Limited Dataset Outpatient Files

Purpose

CMS offers several claim-level files that contain outpatient claims; that is, facility claims submitted for care covered under Part B. Three versions of the LDS files are described:Outpatient file,Outpatient Prospective Payment System (OPPS) file, and OPPS Partial Hospitalization file.

Current Version Date:
05/22/2017
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The OPPS versions contain claims from hospitals that are paid under the outpatient prospective payment system (OPPS). Hospitals that are not paid under OPPS include: Critical Access Hospitals, Indian Health Service hospitals, and hospitals located in American Samoa, Guam, Saipan, and the Virgin Islands. OPPS also applies to partial hospitalization services furnished by Community Mental Health Centers (CMHCs). Certain hospitals in Maryland that are paid under Maryland waiver provisions are also excluded from payment under OPPS.

Outpatient file Hospital Outpatient Prospective Payment System (OPPS) file Hospital Outpatient Prospective Payment System (OPPS) Partial Hospitalization Program
Population included Includes all fee-for-service (FFS) beneficiary Part B institutional claims submitted through the 837I electronic form or on a UB-04 paper form. These include hospital outpatient, renal dialysis, community mental health centers, and other Part B services provided by hospitals, skilled nursing facilities, and home health agencies. Subset of LDS Outpatient file: Includes claims that were paid under the Outpatient Prospective Payment System (OPPS). Subset of LDS Outpatient file: Includes claims that were paid under the OPPS Partial Hospitalization program from Community Mental Health Centers (CMHC).
Approximate # of claims included the 2015 file 152,900,000[1] 86,700,000[2] 79,000[3]
Variables included Includes the maximum number of claims variables available to researchers. See the Outpatient record layout for variable list. Subset of LDS Outpatient file variables: Includes variables that relate to the facility, service, and payment. See the OPPS record layout for the variable list. Subset of LDS Outpatient file variables: Includes variables that relate to the facility, service, and payment. See the OPPS Partial Hospitalization record layout for the variable list.
Can the beneficiaries and facilities be linked to other LDS claims or enrollment files? Yes, both beneficiary identifiers and facility identifiers are linkable to other LDS claims and enrollment files. Beneficiary: DESY_SORT_KEY Facility: ORGNPINM PROVIDER (also known as the CCN) Facility identifiers only: PROVIDER-NUMBER (also known as the CCN) Facility identifiers only: PROVIDER-NUMBER (also known as the CCN)
Table 1. Comparison of three LDS outpatient files
Appendix

 

[1] Medicare CY 2017 Outpatient Prospective Payment System (OPPS) Proposed Rule Claims Accounting. (n.d.). Retrieved January 27, 2017, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1656-P-OPPS-Claims-Accounting.pdf

[2] See footnote #1

[3] Medicare Hospital Outpatient Prospective Payment System (OPPS) Partial Hospitalization Program LDS file page. Retrieved January 31, 2017, from https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/LimitedDataSets/HospitalOPPSPHPLDS.html

For more information about the Outpatient Hospital Claims Processing go to the Medicare Claims Processing Manual, Chapter 4 – Part B Hospital (Including Inpatient Hospital Part B and OPPS).

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Article Information

Acknowledgements:
ResDAC would like to acknowledge Sarah Garcia for assistance with this article.
Level:
Introduction
Topic:
Data Files or Variables, Payment Systems
Program:
Medicare
Category:
Medicare Fee-For-Service Claims
Disclaimer:
The process and materials mentioned as part of this KnowledgeBase article are current, as of the publication date on the article, to the best of our knowledge. The examples provided are correct in the aggregate but may not apply to every subgroup or circumstance that a researcher may wish to study. It is up to the researcher to conduct analysis and confirm that the patterns described in this KnowledgeBase article apply to his/her particular study. If your research findings appear to contradict the advice provided, please contact ResDAC at resdac@umn.edu.