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This variable is contained in the following files: Outpatient (Fee-for-Service)
Short SAS Name
WAGEADJ
SAS Name
REV_CNTR_COINSRNC_WGE_ADJSTD_C

This variable is the beneficiary’s liability for coinsurance for the revenue center record.

Beneficiaries only face coinsurance once they have satisfied Part B’s annual deductible, which applies to both institutional (e.g., HOP) and non-institutional (e.g., Carrier and DME) services.

For most Part B services, coinsurance equals 20 percent of the allowed amount.

The coinsurance amount is wage adjusted, based on the metropolitan statistical area (MSA) where the provider is located.

 

Comments

Medicare payments are described in detail in a series called the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/MLN-Publications.html).

This field is populated for those claims that are required to process through Outpatient PPS PRICER software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers and Critical Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code '07' and certain HCPCS. The above claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

This field will have either a zero (for services for which coinsurance is not applicable), a regular coinsurance amount (calculated on either charges or a fee schedule) or if subject to OP PPS the national coinsurance amount will be wage adjusted. The wage adjusted coinsurance is based on the MSA where the provider is located or assigned as a result of a reclassification.

Source: NCH