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Short SAS Name
CLM_PRCR_RTRN_CD
SAS Name
CLM_PRCR_RTRN_CD

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.

Comments

The payment return code identifies the type of payment calculated by the PRICER software.

Source: NCH

 

Inpatient Hospital Pricer Return Codes
CodeCode value
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
33
For Inpatient PPS, it means 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.
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
CodeCode value
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
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
CodeCode value
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
22
For Long Term Care PPS, it means short stay payment based on blend of LTC-DRG PER DIEM and IPPS comparable amount without outlier.
26
For Long Term Care PPS, it means short stay payment based on IPPS-comparable threshold without outlier.
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
CodeCode value
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
CodeCode value
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
CodeCode value
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
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
CodeCode value
01
Line processed to payment
20
Line processed but payment = 0 bene deductible = > adjusted payment
22
For Outpatient PPS, it means daily coinsurance limitation.
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
CodeCode value
00
ESRD PPS payment calculated
01
ESRD facility rate > zero
22
For ESRD Pricer, it means PPS w/acute comorbid, training.
26
For ESRD Pricer, it means PPS w/chronic comorbid, low volume, training.
31
ESRD Pricer means PPS w/low BMI.
32
ESRD Pricer means PPS w/low volume, onset.
33
For ESRD Pricer, it means PPS w/outlier, training.
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