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Provider Statistical and Reimbursement System User Manual

1. Net Reino 5151125 TOTAL 7 674700 281 11 238835 000 0 00 87709 SOLO 151126 m Patat Nmc WELH SA Freg 1 Grossfes Gross Cash Biood Pac Line item Gross Rew 5192 82 MS Cash Deduct 0 00 DCN 205778846504 Trans Type mer Ga Ka CH het Vata Bede Duit 5 ni mil pa MSP Blood Deduct 0 00 Pant Cntri d 132000000000 Processor ID 14000 0549 ADQS 9 6300 509 3705 000 000 11 14 000 gsm MS Coins 000 Med Rend i Zip Coce 32822 0540 ADOS 1 1522500 2033 515576 SOCO 00 550 39 0 00 tsay Cash Deduct 200 Claim imerest 000 HIC Nune NINGND 0 00 Claim Report Spitz 132 Recpt Dt 04 20 04 Total Amb Trips 3250 2033 15576 0 00 50 33 0 09 105 37 Coins 61 53 Paid Ot 05 14 04 MSP 3200 Sarvice Froex 0227 04 Total Amb Miles 3 6200 509 3706 0 00 11 14 0 09 1532 Psyc Red Service Thru 02 27 04 Nat Reimb 131 29 TOTAL 10 3880 2542 19282 000 61 53 0 09 131 23 Monthly Totals for PETERBORO GENERAL HOSPITAL for service month end 2 29 04 Reimbursements Additional Information Gross GrossFee Cash Blood Lise item Gross Remis 2581 17 MS Cash Deduct 0 00 Units OM pumb Amt Deduct Dedect OME MS Pac Mad man ma MSP Blood Deduct 000 H a i MSP Coins 000 otal Amb s O C Doct Ga soco Blood Dedect 0 00 otai Amb Miles 15 522500 1 896 1553 000 000 3 2000 8185 coas 553862 pa NAA 000 OTAL NO 1135
2. Form Field User Type Validation Error Message ID System Error PS amp R Application is not able to Error E014 Application down Not E014 make reportNet connection at able to make reportNet connection this point Please try again la at this point System Error PS amp R User ID and or password may Error E015 Invalid user ID E015 be invalid and or password System Error PS amp R Exception occurred in the Error E016 E016 LoginAction perform method LoginAction perform amp arg1 System Error PS amp R Exception occurred in the Error E018 Caught exception in E018 selectCMS method selectCMS amp arg1 amp arg2 System Error PS amp R Exception occurred in the Error E023 Caught exception in E023 selectCMSProvidersByType selectCMSProvidersByType method amp arg1 System Error PS amp R Exception occurred in the Error E029 Caught exception in E029 selectFl s method selectFls amp arg1 amp arg2 System Error PS amp R Exception occurred in the Error E030 Caught exception in E030 selectResults method selectResults amp arg1 amp arg2 System Error PS amp R Exception occurred in the Error E032 Caught exception in E032 selectReportsByProviderType selectReportsByProviderType method amp arg1 amp arg2 System Error PS amp R If the admission report radio Error E035 admission report E035 button is checked at least requested but none selected one report admission type P
3. Report Type Data Element Description 399 SCIC 057X All revenue code lines Total Part A and Part B visit count related to home health aide where the first three positions 057 serv during SCIC only episode are rolled up 399 SCIC 058X All revenue code lines Part B other visits with outlier where the first three positions 058 are rolled up 399 SCIC 059X All revenue code lines Total Part A and Part B visit count for all disciplines for SCIC where the first three positions 059 only episodes are rolled up 399 SCIC 060X All revenue code lines Part B oxygen charges with outlier where the first three positions 060 are rolled up 399 SCIC 062X All revenue code lines Part B medical supplies charges with outlier where the first three positions 062 are rolled up 399 SCIC 0623 Displays by itself Part B surgical dressings charges with outlier 399 SCIC All other Rev Codes display as All other Part B revenue code charges they come in on the claim they do not roll up 399 TOTAL 0023 Does not display These fields are not populated on this report 399 TOTAL 027X All revenue code lines Part B medical supplies charges with outlier where the first three positions 027 excluding 0274 are rolled up 399 TOTAL 0274 Displays by itself Part B prosthetics and orthotics charges with outlier 399 TOTAL 029X All revenue codes lines Part B durable medical equipment charges
4. Form Field User Type Validation Error Message ID System Error PS amp R Error retrieving the providers Error E224 Error retrieving E224 for FI by type providers for Fl by type amp arg1 System Error PS amp R Error while preparing to find Error E225 Error preparing to E225 CMS providers by type find CMS providers by type amp arg1 System Error PS amp R Error retrieving the CMS Error E226 Error retrieving CMS E226 providers by type providers by type amp arg1 System Error PS amp R Error while preparing to find Error E227 Error preparing to E227 providers for provider parent find providers for provider parent by type by type amp arg1 System Error PS amp R Error retrieving the providers Error E228 Error retrieving E228 for provider parent by type providers for provider parent by type amp arg1 System Error PS amp R Error while preparing to find Error E229 Error preparing to E229 ownership date for providers find ownership date for providers amp arg1 System Error PS amp R Error retrieving the ownership Error E230 Error retrieving E230 date for providers ownership date for providers amp arg1 System Error PS amp R Error while preparing to find Error E233 Error preparing to E233 Report Codes find Report Codes amp arg1 System Error PS amp R Error retrieving the Report Error E234 Error retrieving E234 Codes ReportCode amp arg1 System Error PS amp R SQL Exception Occurred Err
5. Report Type Data Element Description 755 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 765 CLAIMS Currently this field has no cost report usage 765 UNITS The number of units applicable to each revenue code 765 CHARGES The charges applicable to each revenue code 765 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 765 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 765 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 765 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 765 CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 765 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 765 COINSURANCE The actual coinsurance amount from the paid claim record 765 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance
6. Report Type Data Element Description 399 FULL 057X All revenue code lines Total Part A and Part B visit count related to home health aide where the first three positions 057 service during full episode without outlier are rolled up 399 FULL 058X All revenue code lines Part B other visits without outlier where the first three positions 058 are rolled up 399 FULL 059X All revenue code lines Total Part A and Part B visit count for various disciplines for where the first three positions 059 full episode without outlier are rolled up 399 FULL 060X All revenue code lines This is the total oxygen for full episode where the first three positions 060 are rolled up 399 FULL 062X All revenue code lines This is the total med suppl for full episode where the first three positions 062 are rolled up 399 FULL 0623 Displays by itself This is the total surg dress for full episode 399 FULL AII other Rev Codes display as All other Part B revenue code charges they come in on the claim they do not roll up 399 LUPA 0023 Does not display These fields are not populated on this report 399 LUPA 027X All revenue code lines This is the total medical supplies for full episode where the first three positions 027 excluding 0274 are rolled up 399 LUPA 0274 Displays by itself Part B Prosthetic Orthotic Device charges without outlier 399 LUPA 029X All revenue codes lines This is the total durab
7. eene ene 5 3 5 1 1 72x Hospital Based or Independent Renal Dialysis Center 5 4 5 1 2 xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC 5 5 5 1 3 xxP Outpatient Prospective Payment System sssesesessssss 5 5 5 1 4 xxZ Ambulance Blend 2220002420 IH He eme nnne 5 5 User Manual Table of Contents February 2009 Version No 2 0 ii 5 2 Provider Statistical and Reimbursement System ccu e PAA ae NA AA AA 5 5 5 1 6 xx5 Fee Reimbursed 2222004 III e e e eene nennen enn 5 5 5 1 7 Package Services Assignment ssssssssssssssssm mene 5 6 5 1 8 831 ASC and ASC Fee Schedule After 12 90 cce 5 6 5 19 50x0 CAT OEBIGE Bada NA ta a EU e i ode en Ra Meals avatar E DEI tate LANGAN ds 5 6 5 1 10 xxM Medicare Secondary Payer Lower Cost or Charge MSP LCC 5 6 bil 17 1X2 RAP manda cau td mice e eta Lan aca i rod nd tri Base 5 6 5 1 12 xx9 Episodes seii iode erre ree Ana er pangan RE M de ALTRE a diia 5 6 5 1 13 xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC 5 6 5 1 14 xxP Outpatient Prospective Payment System ssssesesseesssss 5 6 51 15 XXO CAI OUR ER sia cit drea A esa tn a ere Po ah acc CR E t a o abs 5 7 72x Hospital Based or Independent Renal Dialysis Center Report Template 5 7 5 2 1 Hospital Based or Independent Renal Dialysis Center MSP LCC 72A 5 9 5 2 2 Ho
8. 2 22 0 aaa cece eee eee eee teeta teeta ened 4 2 Inpatient Report Footer cece cece ee ener eese ene nena eee neta ened 4 2 Inpatient 11x Provider Summary Report Template Page 1 4 6 Inpatient 11x Provider Summary Report Template Page 2 4 7 Inpatient 11x Provider Summary Report Template Page 3 4 8 Inpatient 11x Payment Reconciliation Detail Report Template ulkum p c 4 9 Inpatient 11x Payment Reconciliation Detail Report Template Last Page Inpatient 115 Provider Summary Report Layout sssesesesseeese 4 11 User Manual February 2009 Version No 2 0 Table of Contents viii Exhibit 4 10 Exhibit 4 11 Exhibit 4 12 Exhibit 4 13 Exhibit 4 14 Exhibit 4 15 Exhibit 5 1 Exhibit 5 2 Exhibit 5 3 Exhibit 5 4 Exhibit 5 5 Exhibit 5 6 Exhibit 5 7 Exhibit 5 8 Exhibit 5 9 Exhibit 5 10 Exhibit 5 11 Exhibit 5 12 Exhibit 5 13 Exhibit 5 14 Exhibit 5 15 Provider Statistical and Reimbursement System Inpatient 115 Payment Reconciliation Detail Report Template First Page dahan Gan aa NANANA AASA AA 4 12 Inpatient 115 Payment Reconciliation Detail Report Template Last PAQ mananamba naa shy nc anag aanhin ana 4 13 Inpatient 18x and 21x Provider Summary Report Template Page 1 4 16 Inpatient 18x and 21x Provider Summary Report Template Page 2 4 17 Inpatient 18x and 21x Paymen
9. User Manual February 2009 Version No 2 0 Report Data B 75 Provider Statistical and Reimbursement System Report Type Data Element Description 730 UNITS Revenue Code 527 The number of units applicable to each revenue code 730 UNITS Revenue Code 528 The number of units applicable to each revenue code 730 UNITS Revenue Code 770 The number of units applicable to each revenue code 730 UNITS Revenue Code 900 The number of units applicable to each revenue code 730 UNITS Revenue Code 910 The number of units applicable to each revenue code 730 UNITS Revenue Code 949 The number of units applicable to each revenue code 730 CHARGES The charges applicable to each revenue code 730 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 730 DESCRIPTI ON The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 730 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 730 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 730 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 730 BLOOD DEDUCTIBLE The actual blood d
10. Monthly Totals for PETERBORO GENERAL HOSPITAL for service month end 2 29 04 Reimbursements Additional Information Gross keimb 3258117 MSP Deductibles 0 00 MSP GRD Rdetn Pye eig Outller 5000 MSP Coins 0 00 Une Changes pump Debs Cim MSP pon Nokt Rd m Claim interest 000 Xr 17 113500 2501 17 000 938 62 000 000 zx us Tot Gross Fee Sehed 306 53 Se ee SE 7 0 00 17 2500 2 581 17 1000 somas 090 1000 sass undi Pee MSP 5 00 Other Adj 2 MSP Recon 9 00 ESRD Rdetn Nowi Pyma en Paye Red Net Reimb 3154255 Feb 21 2007 1 6 2 1000 Consolidated Summary of All Report Types The Consolidated Summary of All Report Types 1000 report can be generated for any provider to consolidate a summary of all report types The report types are grouped according to the following categories e Inpatient reports e Outpatient reports excluding MSP LCC e Outpatient MSP LCC reports e Home Health Agency reports Not all items reported on the Consolidated Summary of All Report Types 1000 report are included on the Medicare Cost Report An example of the 1000 Consolidated Summary of All Report Types report follows User Manual Consolidation Reports February 2009 Version No 2 0 6 2 9 18 49 AM Provider Statistical and Reimbursement System Exhibit 6 2 1000 Consolidated Summary of All Report Types Report Program ID REDESIGN Paid Dates 01 01 04 THRU 10 01 06 Report Run Date 02 01 07 Pro
11. User Manual Outpatient Reports February 2009 Version No 2 0 5 6 Provider Statistical and Reimbursement System 5 1 15 xxO All Other Claims with a bill category of 81 or 82 are presented on the hospice xx0 All Other report template if the MSP LCC Indicator is M or the Full Recovery Indicator is FR 5 2 72x Hospital Based or Independent Renal Dialysis Center Report Template The 72x Hospital Based or Independent Renal Dialysis Center Provider Summary report template displays summary statistic charge reimbursement and additional information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The data displayed in each section is determined by the report selected for generation The statistic section shows the number of claims for each reporting period The charge section displays the number of units and the total dollar amount of the revenue code being reported The reimbursement section displays how Net Reimbursement is calculated Finally the additional information section displays the claim interest payments The 72x Hospital Based or Independent Renal Dialysis Center Payment Reconciliation detail report template is divided into claim information reimbursements and additional information sections The claim infor
12. 029 are rolled up 329 SCIC 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 SCIC 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 SCIC 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 SCIC 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 98 Provider Statistical and Reimbursement System Report Type Data Element Description 329 SCIC 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 SCIC 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 SCIC 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 SCIC 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 SCIC 060X All revenue code lines These fields are not populated on t
13. E316 Select FI MAC s FI MAC Must select an FI MAC s Error E316 No FI MAC s were selected E317 Claim Load Reports CMS If the Invalid Report Types Error E317 No reports Radio Button radio button is not selected were selected this must be selected E317 Invalid Report CMS FI MAC If the Claim Load Reports Error E317 No reports Types Radio Button radio button is not selected were selected this must be selected E318 No Claims loaded PS amp R There must be claims loaded Error E318 No claims for a given provider No reports will be generated with O claims loaded have been loaded for provider ID 5 User Manual February 2009 Version No 2 0 Error Messages C 42 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message E320 The 329 and 339 Box checked None of the Error E320 The 329 and Patient CBSA Visit providers in the request is an 339 Patient CBSA Visit Section HHA Provider two ways to Section is only applicable determine if there is an HHA to HHA Providers and provider in the request a in reports 329 and 339 the report type box a 32x 33x or 34x report is included or b HHA Provider is in the xx3100 xx3199 xx7000 xx8499 xx9000 xx9799 range E321 The 329 and 339 Box Checked At least one Error E321 The 329 and Patient CBSA Visit provider is an HHA Provider 339 Patient CBSA Visit
14. 2 3 xl Fie Edit View Favorites Tools Help a IQ O 8 ie sme etm C Address http pearl ams com psr ui FrontController op FI_SummaryRequestResults amp er FI_SummaryRequestResults jsp amp iorder 6D Ej co vcot E vy Bookmarks ios blocked EF check v cw Autolink v soni mp Sendtow 2 Site Map Announcements Home Report Inbox Request Report Administration summary Report Inbox Detail Report Inbox Miscellaneous Report Inbox LI x Summary Report Inbox Do you want to open or save this file n CMS Test 101608 1t Complete 21 aj E ACMSCONT 5 256790 1 2 pen MART Complete 20 r ACMSCONT S 256669 m pude Complete 14 ri S S 5 1t Complete 13 n ACMSCONT S 256628 i pen Save Complete 13 r ACMSCONT S 256608 ti Complete 12 r ACMSCONT S 256572 1 Always ask before opening this type of fle Complete 11 H SESE While fles from the Intemet can be useful some files can potentially complete H r ACMSCONT S 256570 m Q Harm your computer you do not tust he source do not open or Complete 11 m ACMSCONT S 256549 it save this fle What s the risk Complete 9 r ACMSCONT S 256548 1 A Complete 9 ri S 4 10 03 2008 10121 KB Ex Complete 9 n ACMSCONT S 256535 10 03 2008 2 10121 KB FH Complete 9 r ACMSCONT S 256534 10 03 2008 10121 KB E Complete 9 zl After 21 calendar days with a Status of Complete or Error the report request will no longer
15. 73P DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 73P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 73P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 73P OUTLIER The outlier portion of the OPPS payment for the APC 73P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 73P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 73P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 73P COINSURANCE The actual coinsurance amount from the paid claim record 73P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 73P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 73P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 73P NET REIMBURSEMENT This amount represents an accumulation of interim payments
16. ID Form Field User Type Validation Error Message W010 Insufficient Room in All Users may only save up to Warning W010 The the Favorites 100 requests number of Saved Request s Inbox Favorites limit has been reached This request will be submitted but not saved Do you wish to continue W011 Favorite Name field All The Favorite Name that Warning W011 A was entered already exists Favorite Request with this name already exists Its saved parameters will be lost Do you wish to continue W012 Deleting one or more All After selecting a Delete Warning W012 You are Requests checkbox for one or more about to delete number given request names the of requests selected for user clicks the Delete deletion requests from button your Inbox Request Report Inbox W013 Removing one or All After selecting a Remove Warning W013 You are more Favorite Favorite checkbox for one or about to remove Requests more given favorite names number of requests gt the user clicks the Remove requests from your button Favorites Do you wish to continue W015 Load Control Load FI MAC Admin After clicking the Certify Warning W015 By Certification button button for a load that was clicking Continue you are completed the following certifying that you agree warning is displayed with the following statement have reviewed this load control entry and have determined that the associated claims supplie
17. PDF CSV and PDF amp CSV To the left of each option is the radio button a small empty circle To select one of the options the user selects the appropriate radio button When a radio button is selected a solid circle appears inside of the circle In the PS amp R System report request pages radio buttons are often the first control type with which a user must interact before making additional selections in other standard forms In these instances until the user selects a radio button all of the other standard forms on the page are unavailable and appear grayed out Once a radio button is selected the user can interact with remaining control types that become available and appear darkened 2 3 2 Check Boxes Check boxes enable a user to select any number of choices zero one several or all from a list of options The following exhibit provides an example of check boxes used within the PS amp R System Exhibit 2 10 Check Boxes Exclude 329 and 339 Patient CBSA Visit Section M Include 110 DRG Section Include 1000 Report The example in the exhibit above shows three check box options Exclude 329 and 339 Patient CBSA Visit Section Include 110 DRG Section and Include 1000 Report To the left of each option is the check box a small empty square To select one of the options the user clicks the appropriate check box When a check box is selected a check mark appears inside the box as displayed for the
18. All If one service period s To Error E312 Period E312 date is populated it must service dates do not have a be greater than or equal to valid date range From its corresponding From from date To to date date All If multiple service period Error E312 Period E312 date ranges are provided service dates do not have a service periods 2 3 and valid date range From 4 s From date entry must from date To to date be greater than the previous service period s To Date note previous service period refers to any prior service period that has an entry this may require ignoring service periods without entries This validation assures chronological service periods and that there are no overlapping service periods Exclude For each provider at least Error E102 All service E102 Checkbox one service period s periods excluded for Exclude checkbox must Provider ID 5 not be selected Service Period All Fields must not be null Error E008 Service start E008 From Dates in Selected Service Periods Table date must be on or after 2006 FYE Date plus 1 day User Manual February 2009 Version No 2 0 Error Messages C 5 Provider Statistical and Reimbursement System Form Field User Type Validation Error Warning Message ID Service Period All Fields must not be null Error E038 Service E038 From Dates in Date s entr
19. CAIS Provider Statistical amp Reimbursement System Site Map Provider Statistical amp Reimbursement System General Links CMS gov Announcements FAQ Help Logout Login User Specific Links Home User Preferences Report Inbox Summary Reports Detail Reports Miscellaneous Reports Request Reports Favorite Requests Request Summary Request Detail Request Miscellaneous Load Control Report 30 Day Load Activity Administration Background Manager Report Scheduler System Parameters User Manual System Overview and Common Features February 2009 Version No 1 2 5 Provider Statistical and Reimbursement System 2 2 1 3 Announcements When selected the Announcements hyperlink displays announcements pertaining to the type of user currently accessing the PS amp R System The following exhibit provides an example of the Announcements page in the PS amp R System Exhibit 2 5 Announcements Page Site Map Announcements FAQ Help Logout CATS Provider Statistical amp Reimbursement System User ID CMTESTOO Centers for Medicare and Medicaid Services Tuesday November 18 PS amp R Announcements Home ReportInbox Request Report Administration PS amp R Announcements The Redesigned Provider Statistical and Reimbursement System Will Be Operational in the First Quarter of 2009 System Overview and Common Features User Manual February 2009 Version No 1 2 6 Provider Statistical and Reimb
20. Definition Dialysis Facility Renal A unit hospital based or freestanding that is approved to furnish dialysis services directly to End Stage Renal Disease patients DRG Diagnostic Related Group patients with similar illness End Stage Renal Disease ESRD Permanent kidney failure requiring a regular course of dialysis or kidney transplantation to maintain life End Stage Renal Disease Treatment Facility A facility other than a hospital that provides dialysis treatment maintenance and or training to patients or caregivers on an ambulatory or home care basis Federally Qualified Health Center FQHC Health centers that have been approved by the government for a program to give low cost health care in a medically underserved area Medicare pays for some health services in Federally Qualified Health Centers that are not usually covered like preventive care Federally Qualified Health Centers include community health centers tribal health clinics migrant health services and health centers for the homeless Fiscal Intermediary F1 An agency or organization under contract with CMS that performs any or all of the following functions processing claims all claims for Medicare Part A services and for certain part B services furnished by institutional providers determining reasonable charges determining accuracy and coverage of claims and making Medicare payment for only covered and medically n
21. OUTLIER This field will show the outlier portion of the PPS payment for capital 11U HOLD HARMLESS This field shows the hold harmless amount paid for old capital based on the hold harmless old capital method 11U DSH This is the disproportionate share portion of the PPS capital payment 11U INDIRECT MEDI CAL EDUCATION This is the indirect medical education adjustment payment to PPS teaching hospitals applicable to PPS capital payments 11U EXCEPTI ONS This is the per discharge exception interim payment for capital related costs that qualifying hospitals are entitled to receive in accordance with Medicare payment policy 11U TOTAL CAPITAL PAYMENTS This is the sum of the capital amounts for HSP FSP outlier hold harmless disproportionate share adjustment indirect medical education and exception payments 11U GROSS REIMBURSEMENT This amount is the sum of total operating and total capital payments 11U DEVICE CREDIT This amount represents the credit that a provider received to replace a medical device that may have been defective or under warranty This amount can be identified with a value code of FD on the claim User Manual February 2009 Version No 2 0 Report Data B 28 Provider Statistical and Reimbursement System Report Type Data Element Description 11U CASH DEDUCTIBLE The sum of actual cash deductible amount
22. Provider Statistical and Reimbursement System Report Type Data Element Description 11K OUTLIER Summarizes cost outlier payments Value code 17 made under the Prospective Payment System 11K DSH LIP The DSH LIP amount value code 18 shown on the PS amp R report represents interim payments calculated by the PPS Pricer program For cost reporting purposes the DSH LIP amount must be recomputed for qualifying hospitals 11K IME TEACHING AD Indirect medical education Teaching adjustment Value Code 19 amount shown on the PS amp R are estimated payments made on a bill by bill basis by the PPS Pricer program For cost reporting purposes the amount must be recomputed 11K NEW TECHNOLOGY Summarizes new technology payments Value code 77 made under the Prospective Payment System 11K IPF ECT Summarizes IPF ECT Inpatient Psych Facility Electro Convulsive Therapy payments made under the Prospective Payment System 11K TOTAL OPERATING PAYMENTS This is the sum of the operating amounts for HSP FSP outlier DSH LIP IME teaching adjustment new technology IPF ECT and exception payments 11K HOSPITAL SPECIFIC This is the hospital specific portion of the PPS payment for capital The field will be zero for providers paid based on the hold harmless old capital or the hold harmless 100 percent federal method and for new hospitals during their first two years of operatio
23. 710 UNITS Revenue Code 522 The number of units applicable to each revenue code User Manual February 2009 Version No 2 0 Report Data B 74 Provider Statistical and Reimbursement System Report Type Data Element Description 710 UNITS Revenue Code 524 The number of units applicable to each revenue code 710 UNITS Revenue Code 525 The number of units applicable to each revenue code 710 UNITS Revenue Code 527 The number of units applicable to each revenue code 710 UNITS Revenue Code 528 The number of units applicable to each revenue code 710 UNITS Revenue Code 770 The number of units applicable to each revenue code 710 UNITS Revenue Code 900 The number of units applicable to each revenue code 710 UNITS Revenue Code 910 The number of units applicable to each revenue code 710 UNITS Revenue Code 949 The number of units applicable to each revenue code 710 CHARGES The charges applicable to each revenue code 710 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 710 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 710 TOTAL COVERED CHARGES All Medicare covered charges associated
24. 760 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 850 CLAI MS Currently this field has no cost report usage 850 UNITS The number of units applicable to each revenue code 850 CHARGES The charges applicable to each revenue code User Manual February 2009 Version No 2 0 Report Data B 78 Provider Statistical and Reimbursement System Report Type Data Element Description 850 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 850 DESCRIPTI ON The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 850 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 850 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 850 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 850 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 850 COINSURANCE The actual coinsurance amount from the paid claim record 850 NET MSP PAYMENTS The net payment m
25. 820 MEDI CARE DAYS Currently this field has no cost report usage 820 CLAIMS Currently this field has no cost report usage 820 TOTAL UNDUPLI CATED CENSUS The unduplicated census count of the hospice for all patients COUNT initially admitted and filing an election within the reporting period 820 UNDUP DAYS Currently this field has no cost report usage 820 HOURS The number of hours applicable to this revenue code 820 UNITS REV CODE 0651 The number of units applicable to each revenue code 820 UNITS REV CODE 0652 The number of hours applicable to this revenue code 820 UNITS REV CODE 0655 The number of units applicable to each revenue code 820 UNITS REV CODE 0656 The number of units applicable to each revenue code 820 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 820 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 820 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 820 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 820 DEDUCTIBLES The actual deductible amount from the paid claim record 820 COINSURANCE The actual coinsurance amount from the paid claim record 820 NET MS
26. ASC and ASC Fee Schedule MSP LCC 83A Critical Access Hospital MSP LCC 85A xxP Outpatient Prospective Payment System OPPS Report Template Inpatient Part B OPPS 12P Outpatient OPPS 13P Outpatient Other OPPS 14P SNF Outpatient OPPS 22P SNF Outpatient OPPS 23P SNF Outpatient OPPS 24P Home Health Outpatient OPPS not HHPPS 34P Clinic Rural Health OPPS 71P Federally Qualified Health Center OPPS 73P Rehabilitation Facility OPPS 74P Comprehensive Outpatient Rehabilitation Facilities OPPS 75P Community Mental Health Center OPPS 76P Hospice Non Hospital Based OPPS 81P Hospice Hospital Based OPPS 82P ASC and ASC Fee Schedule OPPS 83P User Manual Outpatient Reports February 2009 Version No 2 0 5 1 Provider Statistical and Reimbursement System e xxZ Ambulance Blend Report Template Inpatient Ambulance Blend Effective 04 01 02 12Z Outpatient Ambulance Blend Effective 04 01 02 13Z SNF Ambulance Blend Effective 04 01 02 22Z SNF Ambulance Blend Effective 04 01 02 23Z ASC and ASC Fee Schedule Ambulance Blend Effective 04 01 02 83Z Critical Access Hospital Ambulance Blend Effective 04 01 02 85Z xx2 Vaccines Report Template Inpatient Part B Vaccine 122 Outpatient Part B Vaccine 132 Outpatient Other Vaccines 142 SNF Inpatient Vaccine Part B 100 96 Reasonable Cost 222 SNF
27. Claim lines that do not satisfy requirements for presentation on any of the previously processed report templates are presented on the xxO all Other report template The following sections document the Home Health Agency report type assignments 5 1 10 xxM Medicare Secondary Payer Lower Cost or Charge MSP LCC Claims with a type of bill of 32x or 33x are presented on the home health agency xxM xx9 Home Health Agency report template if the MSP LCC Indicator is M or the Full Recovery Indicator is FR 5 1 11 xx2 RAP Claims with a type of bill of 32x or 33x are presented on the home health agency xx2 RAP report template if the Home Health Split Indicator is R 5 1 12 xx9 Episodes Claims with a type of bill of 32x or 33x are presented on the home health agency xx9 Episodes report template if the claim is not presented on the xx2 RAP report template 5 1 13 xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Claims with a bill category of 81 or 82 are presented on the hospice xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC report template if the MSP LCC Indicator is M or the Full Recovery Indicator is FR 5 1 14 xxP Outpatient Prospective Payment System Claims with a bill category of 81 or 82 are presented on the hospice xxP Outpatient Prospective Payment System report template if the MSP LCC Indicator is M or the Full Recovery Indicator is ER
28. FAQ Help Logout AA User ID TRTEST17 rsday August 23 Summary Report Vien necs Home Report Inbox Request Report Favorite Requests Request Summary Request Detail Summary Report Request 5 Select Report Format PDF C csv C PDF amp csv T Separate Files by Provider Bock 8 Select the report format radio button to specify the type of report format portable document format PDF comma separated values CSV or both PDF and CSV formats Note if you select to generate a PDF file that results in an excessively large PDF file you will be prompted to change your reporting parameters or to User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 13 Provider Statistical and Reimbursement System select the CSV option Click the Separate Files by Provider check box to produce a single ZIP file containing a separate output file for each provider 9 Click Continue to continue to the next page to specify the request name and to view the selection criteria for the report s or click Back to return to the previous page The following page appears if you click Continue Provider Statistical 4 Reimbursement System site Map Announcements FAQ Help Logout E GLOBAL FI MAC 14000 User ID TR Summary Report Request HERES i Home Report Inbox Request Report Favorite Requests Request Summary Request Detail Summary Report Request 6 Confirm Report Request Report Request
29. From from date To to date All Entry must be less than the Error E092 Service Periods E092 next Service Period From overlap and or are not Date this assures chronological for Provider chronological service ID 5 periods and that there is no overlapping service periods All Field must not be null Error E042 Paid Date s E042 entry contains a non numeric character or is not in MM DD YYYY format Paid Date From All Only numeric characters Error E042 Paid Date s E042 Date entry contains a non numeric character or is not in MM DD YYYY format All Entry must be in Error E042 Paid Date s E042 MM DD YYYY format entry contains a non numeric character or is not in MM DD YYYY format All Month Day and Year Error E001 Paid Date s E001 values must be valid entry contains an invalid month day and or year User Manual February 2009 Version No 2 0 Error Messages C 7 Provider Statistical and Reimbursement System Form Field User Type Validation Error Warning Message ID All Entry must be greater than Error E008 Paid From E008 or equal to 01 01 2006 date must be on or after 01 01 2006 All Entry must be less than or Error E312 Paid Dates do E312 equal to the Paid Date To not have a valid date range Date From from dates To to dates All Field must not be null Error E042 Paid Date s E042 entry
30. MS Cash Dedect MS Blood Deduct MS Coins Caic Raimb PIP Actual Cim Pymnts PIP Claim Interest Additional information MS Cash Dedect MS Blood Deduct MS Coins Caic Reimb PIP Actual Cim Pymnts PIP Claim Interest User Manual February 2009 Version No 2 0 Inpatient Reports 4 18 000 000 000 000 000 1621 000 000 000 000 000 020 000 020 020 000 162 33626 PM Provider Statistical and Reimbursement System Exhibit 4 15 Inpatient 18x and 21x Payment Reconciliation Detail Report Template Last Page PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page 20 Service Month End N A SWING BED SNF Report OD24202 Report Run Date 02 07 07 Report Type 180 Provider FYE 12 21 Paid Dates 01 01 04 to 10 01 06 Provider Number T0Z300 SNOW BIRD HOSPITAL Service Period and Report Type Totals Service Period Reimbursements Additional Information 01 01 2004 03 30 2006 Units Charges Gross Reimb 890 970 00 MSP Cash Deduct 0 00 1 Disc 5 sal MG MSP Blood Deduct 0 00 Med Days 1 053 Discharge Count B5 TOTAL 5887 057637 LE aye rge Cou OTA 35887 5223267537 LESS MSP Oii 040 Cash Deduct 020 CaicReimb PIP 0 00 Blood Deduct 020 Actual Cim Pymnts PP 0 00 Coins 10 34350 Claim interest 162 MS 0 00 Net Remb 180 626 50 Report Type 180 Totals for SNOW BIRD HOSPITAL Resmbursements Additional informati
31. System Error PS amp R Error retrieving the Load Error E204 Error retrieving Load E204 Detail Hold reports Detail Hold Report amp arg1 System Error PS amp R Error while preparing to get Error E205 Error preparing to get E205 Load Detail Hold History Load Detail Hold History Report reports amp arg1 System Error PS amp R Error retrieving the Load Error E206 Error retrieving Load E206 Detail Hold History reports Detail Hold History Report amp arg1 System Error PS amp R Error while preparing to get Error E207 Error preparing to get E207 Load Detail Release History Load Detail Rlse History Report reports amp arg1 System Error PS amp R Error retrieving the Load Error E208 Error retrieving Load E208 Detail Release History reports Detail Rlse History Report amp arg1 System Error PS amp R Error while preparing to find Error E209 Error preparing to E209 the selected provider find Provider amp arg1 System Error PS amp R Cannot find the provider with Error E210 Provider not found E210 the specified key with key amp arg1 System Error PS amp R Error retrieving the selected Error E211 Error retrieving E211 provider Provider amp arg1 System Error PS amp R Error when closing the Error E212 Error closing E212 connection connection System Error PS amp R Error while preparing to find Error E213 Error preparing to E213 the selected providers find Providers amp arg1 System Error PS amp R Error retrieving the s
32. ux Gross Reimb 415 22 MSP Cash Deduct sana DCN 204381390412605 Trans Type Gross Blood oint Owhd MSP Blood Deduct sana Punt Ctt a 559000000000 Processor ID 14000 Reimb Deduct Deduct NAG ies MSP Coins 0 00 Med Rerd Cash Deduct 000 Claim interest 000 HIC Num 1470671790 0 00 Blood Deduct 009 Stndrd Ovrhd Amt 1 082 59 Recpt Dt 05 17 04 2 00 Coin 5230 58 Claim Report Split 76P Paid Dt 04 30 04 0 00 MSP 000 Service Frome 05 08 04 0 00 Net Reimb 184 54 Semice Thru 05 14 04 0 00 0 00 0 00 0 00 0 00 0 00 16 1 153 40 41522 0 00 000 23068 000 18454 1 06259 Monthly Totals for PARROTHEAD MEDICAL CENTER for service month end 6 30 00 Reimbursements Additional Information Stdrd Gross Reimb 841522 MSP Cash Deduct 50 00 Gross Cash Blood Une kam Units Charges Com MS Ovrhd MSP Blood Deduct 0 00 Reimb Deduct Deduct Remb pint LESS aip Cima 000 TOTAL 16 51 15340 41522 000 000 23068 000 18454 1 08259 Cash Deduct 0 00 Claim Interest 0 00 Blood Deduct 0 00 Stn rd Ovrhd Amt 1 082 59 Coins 230 68 MSP 0 00 Net Reimb pil Feb 19 2007 2 10 37 23 AM User Manual Outpatient Reports February 2009 Version No 2 0 5 54 Provider Statistical and Reimbursement System 6 Consolidation Reports The PS amp R System consists of consolidation reports that are based on standardized inpatient and outpatient report templates The consolidation rep
33. 058 are rolled up 399 LUPA 059X All revenue code lines Total Part A and Part B visit count for all disciplines for LUPA where the first three positions 059 episodes are rolled up 399 LUPA 060X All revenue code lines Part B Oxygen charges without outlier where the first three positions 060 are rolled up 399 LUPA 062X All revenue code lines Part B Med Supplies charges without outlier where the first three positions 062 are rolled up 399 LUPA 0623 Displays by itself Total Part B Surgical Dressings charges without outlier 399 LUPA All other Rev Codes display as All other Part B Revenue Code Charges they come in on the claim they do not roll up 399 PEP 0023 Does not display These fields are not populated on this report 399 PEP 027X All revenue code lines Part B Med Supplies charges with outlier where the first three positions 027 excluding 0274 are rolled up 399 PEP 0274 Displays by itself Part B Prosthetics and Orthotics charges with outlier 399 PEP 029X All revenue codes lines Part B Durable Med Equip charges with outlier where the first three positions 029 are rolled up 399 PEP 042X All revenue code lines Total Part A and Part B physical therapy visit count during PEP where the first three positions 042 episode are rolled up 399 PEP 043X All revenue code lines Total Part A and Part B occupational therapy visit count during where the first three positions 043 PEP episode a
34. 058 are rolled up 399 TOTAL 059X All revenue code lines Total Part A and Part B visit count for all disciplines for all where the first three positions 059 disciplines are rolled up 399 TOTAL 060X All revenue code lines Total Part B oxygen charges without outlier where the first three positions 060 are rolled up 399 TOTAL 062X All revenue code lines Total Part B Med Supplies charges without outlier where the first three positions 062 are rolled up 399 TOTAL 0623 Displays by itself Total Part B Surgical Dressings charges without outlier 399 TOTAL All other Rev Codes display as All other Part B Revenue Code Charges they come in on the claim they do not roll up 399 SERVICES WITH OUTLIER 399 FULL 0023 Does not display These fields are not populated on this report 399 FULL 027X All revenue code lines Total Part A and Part B med supplies payments where the first three positions 027 excluding 0274 are rolled up 399 FULL 0274 Displays by itself Part B Prosthetics and Orthotics charges with outlier 399 FULL 029X All revenue codes lines Total Part A and Part B durable medical equipment where the first three positions 029 payments are rolled up 399 FULL 042X All revenue code lines Physical therapy visit count during full episode with outlier where the first three positions 042 are rolled up 399 FULL 043X All revenue code lines Occupational therapy visit count during full episode with w
35. 120 00 0 0 00 0 0 00 0 0 00 s 23000 0 0 00 0 000 LJ 0 00 5 232 00 L 000 L 000 o 0 00 17 1 095 50 000 o 0 00 L 0 00 n 1 150 00 0 000 0 0 00 0 00 2 604 00 0 000 0 000 0 00 2 292 00 000 0 0 00 0 0 00 2 1 568 00 0 0 00 L 000 o 0 00 2 340 00 o 0 00 0 0 00 0 0 00 132 7 077 20 0 000 0 000 0 00 9 161 20 0 00 0 00 0 00 0 00 0 00 000 1 1 29 49 PM User Manual February 2009 Version No 2 0 Inpatient Reports 4 6 Exhibit 4 5 Provider Statistical and Reimbursement System Inpatient 11x Provider Summary Report Template Page 2 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page 2 Paid Dates 07 01 04 THRU 11 20 06 INPATIENT FART A MSP LCC Report OD44203 Report Run Date 03 22 06 Report Type 11A Provider FYE 06 20 Provider Number 100001 SHANDS JACKSONVILLE MEDICAL CENTER SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 10 01 04 09 30 05 10 01 05 09 30 06 10 01 06 09 20 07 10 01 07 09 30 08 FEDERAL SPECIFIC 0 00 6 944 66 0 00 000 OUTUER 0 00 0 00 0 00 0 00 DSH UP 0 00 3 373 03 000 000 IME TEACHING ADJ 0 00 2 089 77 0 00 0 00 NEW TECHNOLOGY 0 00 0 00 0 00 0 00 IPF ECT 0 00 0 00 0 00 0 00 TOTAL OPERATING PAYMENTS 0 00 14 407 46 0 00 0 00 CAPITAL HOSPITAL SPECIFIC 0 00 0 00 0
36. 151 15 Led Feb 7 2007 1 2 29 56 PM The reports that are generated based on the outpatient 81x 82x Hospice report template are Hospice Non Hospital Based MSP LCC 81A Hospice Non Hospital Based 810 Hospice Hospital Based MSP LCC 82A e Hospice Hospital Based 820 A brief description of these reports is provided in the following sections 5 11 1 Hospice Non Hospital Based MSP LCC 81A The Hospice Non Hospital Based MSP LCC 81A report summarizes the non hospital based free standing hospice claims that are subject to Medicare Secondary Payer Lower Cost or Charge MSP LCC limitation The items reported on the Hospice Non Hospital Based MSP LCC 81A report are not to be included on the Medicare Cost Report User Manual Outpatient Reports February 2009 Version No 2 0 5 49 Provider Statistical and Reimbursement System 5 11 2 Hospice Non Hospital Based 810 The Hospice Non Hospital Based 810 report summarizes the non hospital based freestanding hospice claim data The items reported on the Hospice Non Hospital Based 810 report are included on the Medicare Cost Report 5 11 3 Hospice Hospital Based MSP LCC 82A The Hospice Hospital Based MSP LCC 82A report summarizes hospital based provider hospice claims that are subject to the MSP LCC limitation The items reported on the Hospice Hospital Based MSP LCC 82A report are not to be included on the Medica
37. 339 PEP 042X All revenue code lines where the first three positions 042 are rolled up These fields are not populated on this report 339 PEP 043X All revenue code lines where the first three positions 043 are rolled up These fields are not populated on this report 339 PEP 044X All revenue code lines where the first three positions 044 are rolled up These fields are not populated on this report 339 PEP 055X All revenue code lines where the first three positions 055 are rolled up These fields are not populated on this report 339 PEP 056X All revenue code lines where the first three positions 056 are rolled up These fields are not populated on this report 339 PEP 057X All revenue code lines where the first three positions 057 are rolled up These fields are not populated on this report 339 PEP 058X All revenue code lines where the first three positions 058 are rolled up These fields are not populated on this report 339 PEP 059X All revenue code lines where the first three positions 059 are rolled up These fields are not populated on this report 339 PEP 060X All revenue code lines where the first three positions 060 are rolled up These fields are not populated on this report 339 PEP 062X All revenue code lines where the
38. 339 FULL 0274 Displays by itself These fields are not populated on this report 339 FULL 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 115 Provider Statistical and Reimbursement System Report Type Data Element Description 339 FULL 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 FULL 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 FULL 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 FULL 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 FULL 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 FULL 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 FULL 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 FULL 059X All re
39. 489 63 55 00 00 200 8 90 2 558 10 2 00 0 00 sano 8 23 313 05 90 200 000 438 71 20 2 00 20 00 0 00 9 97 0490 62289 686 55 000 0 00 5137I 000 96 12 TOTAL 7 122805 41755 000 000 245 61 0 00 171 94 36496 Sinara Gross Cah Mood Une ltem Uds Caps Qus Dot Deut 208 MP map OP 3 8122805 41755 000 000 2456 000 17194 36496 PAYMENT RECONCILIATION REPORT ASC AND ASC FEE SCHEDULE AFTER 12 90 Reimbursements Gross Reimb 841755 LESS Cash Deduct 000 Blood Deduct 000 s 245 51 000 Net Reimbi 171 94 Reimbursements Gross Reimb 417 55 LESS Cash Deduct 0 00 Blood Deduct 0 00 Coins 245 61 Ms 000 Net Reim 171 94 Page 1 Report 0044202 Report Type 831 Pald Dates 01 01 80 to 10 01 06 Additional Information MSP Cash Deduct 000 MSP Blood Deduct 000 MSP Coins 0 00 Claim Interest 000 Stndrd Ovrhd Amt 836496 Ciaim Report Splits 8 Additional Information MSP Cash Deduct 000 MSP Blood Deduct 0 00 MSP Coins 000 Claim Interest 000 Stndrd Ovrhd Amt 536496 10 37 23 AM User Manual February 2009 Version No 2 0 Outpatient Reports 5 51 Provider Statistical and Reimbursement System Exhibit 5 29 Outpatient 831 ASC and ASC Fee Schedule After 12 90 Provider Summary Report Last Page Program ID REDESIGN Service Month End N A Report Run Date 02 19 07 Provider FYE 09 30 Provider Number T00
40. 82A Hospice Hospital Based Outpatient Hospice 1500 1799 Yes MSP LCC 82P Hospice Hospital Based Outpatient Hospice 1500 1799 Yes OPPS 820 Hospice Hospital Based Outpatient Hospice 1500 1799 Yes 83A ASC and ASC Fee Schedule Outpatient Hospital Group 0001 0999 No MSP LCC 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 S001 S999 TO00 T999 M300 M399 R300 R399 User Manual February 2009 Version No 2 0 Report Details A 10 Provider Statistical and Reimbursement System Report Type Report Name Service Category Provider Type s Provider Number Range Cost Report Yes No 83P ASC and ASC Fee Schedule OPPS Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 83Z ASC and ASC Fee Schedule Ambulance Blend Effective 04 01 02 Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 832 ASC and ASC Fee Schedule Vaccine Part B 10096 Reasonable Cost Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 831 ASC and ASC Fee Schedule After 12 90 Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 59
41. All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 LUPA 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 LUPA 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 LUPA 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 LUPA 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 LUPA 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 LUPA 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 LUPA 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 LUPA 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 LUPA 0623 Displays by itself These fields are not populated on this report 339 LUPA All other Rev Codes display as These fields are not populated on this report they come in on the claim the
42. E069 Dates by Period contain only numeric entry contains a non numeric characters character or is not in MM DD YYYY format All All date field entries must be Error E069 Service Date s E069 in MM DD YYYY format entry contains a non numeric character or is not in MM DD YYYY format All All date fields Month Day Error E001 Service Date s E001 and Year values must be entry contains an invalid valid month day and or year All If one service period s To Error E312 Period E312 date is populated it must be service dates do not have a greater than or equal to its valid date range From from corresponding From date date To to date Update Service All Service start dates must come Error E008 Service start E008 Dates by after the provider s 2006 FYE date must be on or after Provider s Start Date plus one day 2006 FYE Date plus 1 day Date Update Service All Field must not be null Error E038 Service Date s E038 Dates by entry for Provider ID Provider s contains a non numeric From Date character or is not in MM DD YYYY format User Manual February 2009 Version No 2 0 Error Messages C 12 Provider Statistical and Reimbursement System Form Field User Type Validation Error Warning Message ID All Only numeric characters Error E038 Service Date s E038 entry for Provider ID contains a non numeric character or is
43. Fee Reimbursed 725 The Hospital Based or Independent Renal Dialysis Center Fee Reimbursed 725 report shows covered charges and reimbursement by revenue code for fee reimbursed services for hospital based or independent renal dialysis center services The items reported on the Hospital Based or Independent Renal Dialysis Center Fee Reimbursed 725 report are not to be included on the Medicare Cost Report 5 3 XxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Report Template The reports generated based on the Medicare Secondary Payer Lower Cost or Charge MSP LCC contain data at the claim level The Outpatient xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Provider Summary report template displays summary statistic charge reimbursement and additional information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The data displayed in each section is determined by the report selected for generation The statistic section shows the number of claims for each reporting period The charge section displays the number of units and the total dollar amount of the revenue code being reported The reimbursement section displays how Net Reimbursement is calculated Finally the additional information section displays the claim interest
44. Pricer Rt Ce 0 5364501 000 3643 15 Claim Report Splits 510 Mad Rerd 449000000000 Processor iO 14000 10203 35303 310203 10203 Deductblex 5 00 HIC Name 11999060 5 Ib 121 54 9911 12164 12154 Coins na Recpt Ot 04 07 04 H l DB 2 00 Pad Dt 11 03 04 TOTAL 36 3872 68 223 67 387283 MSP Recon 2 00 Service From 03 01 04 Other Ads 200 Service Thru 03 31 04 Net Raimb 3872 83 Mad Days Patnt New ERCO BillFrec Ba Undup Grossfee Gros Gross Remb 3721 65 Claim Interest 0 00 DCN 202446528170304 01 Trans Type D Code Desripton Des Mx Un Cups NCS na Nairb me Patient CBSA 9910 Ptt Cntri 8 100000000000 Pricer Rt C e 31 5354187 0 99 5349501 Claim Report Splits 510 Mad Rerd 449900000000 Processor i 14006 1 10203 93303 102 03 10203 Deductbler 0 00 HIC Num 1615687680 T gt Coins 0 00 21 64 93311 12154 512164 Racpt Dt 10 29 04 i 2 i Ms 0 00 Pad Dt 11 03 04 TOTAL 36 3 765 54 522367 3 721 68 MS Recon 6 09 Service From 03 01 04 Other Adis 200 Service Thru 03 31 04 Nat Raimb 372165 Mad Dayz Monthly Totals for BIRD SONG HOSPICE for service month end 3 31 04 Reimbursements Additional Information 1511 Undup Wara c GrossFee Gross Gross Raimb 151 15 Claim interest 000 Med Days Days v Raimb Remb LESS TOTAL o 107 14 0 00 151 15 Deducbbles 2 00 Coins 2 00 MSP 5 00 MS Recon 2 00 Other Ads 2 00 Net Raimb
45. ReportNet connection at this point Cognos ReportNet PS amp R If a Job ID has been deleted Error E172 No Job History E172 Error on the Reporting side there found for the job with Job ID will be no history of that job job ID gt Illegal Character Valid for the All non alpha numeric Error E331 Security E331 Security Error entire PS amp R characters excluding the Exception encountered system following characters Please call Help Desk excluding the S PCs Your Request Jur our aa Name field of y a the pio 1 EJ Confirmation Screens No t DA Please refer to will generate a security Error E152 for error documentation relating to the Your Request Name field C 16 Miscellaneous System Error Messages Miscellaneous system error messages are presented in the following table Exhibit C 16 Miscellaneous System Error Messages Form Field User Type Validation Error Message ID Login PS amp R User session has expired Error E011 User not logged in E011 Please login before continuing Please login System Error PS amp R Exception occurred in the E012 Caught exception in E012 selectProviderRanges method selectProviderRanges amp arg1 amp arg2 System Error PS amp R Exception occurred in the E013 Caught exception in E013 selectReports method selectReports amp arg1 User Manual February 2009 Version No 2 0 C 22 Error Messages Provider Statistical and Reimbursement System
46. TOTAL COVERED CHARGES o 0 00 35 1 398 20 REIMBURSEMENT SECTION GROSS REIMBURSEMENT 0 00 435 95 LESS CASH DEDUCTIBLE 0 00 0 00 BLOOD DEDUCTIBLE 0 00 0 00 COINSURANCE 0 00 0 00 NET MSP PAYMENTS 0 00 0 00 PSYCH REDUCTION 0 00 0 00 NET REIMBURSEMENT 0 00 435 95 ADDITIONAL INFORMATION SECTION CLAIM INTEREST PAYMENTS 0 00 0 00 Feb 1 2007 1 8 20 03 PM User Manual Outpatient Reports February 2009 Version No 2 0 5 30 Provider Statistical and Reimbursement System Exhibit 5 15 Outpatient xx5 Fee Reimbursed Payment Reconciliation Detail Report Template First Page Program ID REDESIGN Service Month End 03 21 04 Report Run Date 02 07 07 Provider FYE 12 31 Provider Number T00073 CROSS YOUR HEART HOSPITAL Patat Nm DCN Pang Cntri Mad Rerd amp HIC Num Recpt Dt Paid Ot Service From Service Thng Patat Nm DCN Pint Cntri a Mod Rerd amp HIC Num Recpt Ot Paid Ot Service From Service Thr BOGGR 20456055151504 373325945A 05 14 04 03 24 04 CURRB 20458077752504 902090000000 90 022c0020 452266141 D 04 30 04 05 1404 03 1104 03 25 04 BiR Freq Trans Type Processor ID BIR Freq Trans Type Processor ID PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PAYMENT RECONCILIATION REPORT OUTPATIENT FEE REIMBURSED Monthly Totals for CROSS YOUR HEART HOSPITAL for service month end 3 31 04 Feb 7 2007 1 Rey Panel Gross Cash Blood Psg Line i
47. This field does not apply and will be zero DISCHARGES 115 CLAIMS Currently this field has no cost report usage 115 UNITS The number of units applicable to each revenue code 115 CHARGES The charges applicable to each revenue code 115 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 115 DESCRIPTI ON The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 115 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 115 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 115 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 115 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 115 COINSURANCE The actual coinsurance amount from the paid claim record 115 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 115 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustment
48. adjustments etc User Manual February 2009 Version No 2 0 Report Data B 46 Provider Statistical and Reimbursement System Report Type Data Element Description 13P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 13P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 14P CLAIMS Currently this field has no cost report usage 14P UNITS The number of units applicable to each revenue code 14P CHARGES The charges applicable to each revenue code 14P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 14P DESCRIPTI ON The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 14P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 14P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 14P OUTLIER The outlier portion of the OPPS payment for the APC 14P GR
49. amp CSV Paid Dates Include all Paid Dates available at time of report generation Service Periods a ee a 1 ID Provider ITO0007 From 01 01 2006 From 04 01 2006 From 07 01 2006 From 10 01 2006 r To 03 31 2006 To 06 30 2006 To 09 30 2006 To 12 31 2006 ml Note This request will generate up to 15 Summary Report s Data does not exist for the Provider Report combinations listed as No Data Available for the chosen Service Paid Date Periods therefore no report s will be generated for these providers reports I Save Request as Favorite Favorite Name 50 Char FAV TRTEST17 5 T00007 QUARTERLY Modity Cancel You can navigate to the Summary Report Inbox or the Detail Report Inbox by clicking the request name hyperlink corresponding to the recently run request name Refer to section 3 4 Report Inbox for additional information about the Summary Report Inbox and the Detail Report Inbox User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 7 Provider Statistical and Reimbursement System 3 3 Request Summary Reports Perform the following steps to request a summary report 1 Select the Request Summary option from the Request Report menu The following page appears Provider Statistical amp Reimbursement System Site Map Announcements FAQ GLOBAL FI MAC 14000 Help Logout User ID TRTEST17 Thursday August 23 Summary Report Request Home Report Inbox Requ
50. charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 342 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 342 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 342 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 342 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record User Manual February 2009 Version No 2 0 Report Data B 68 Provider Statistical and Reimbursement System Report Type Data Element Description 342 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 342 COINSURANCE The actual coinsurance amount from the paid claim record 342 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 342 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 342 CLAIM INTEREST PAYMENTS Interest payments are accumulated pr
51. med supplies payments where the first three positions 027 excluding 0274 are rolled up 399 FULL 0274 Displays by itself Part B Prosthetic Orthotic Device charges without outlier 399 FULL 029X All revenue codes lines This is the total Part A and Part B durable medical where the first three positions 029 equipment payments are rolled up 399 FULL 042X All revenue code lines Total Part A and Part B physical therapy visit count during full where the first three positions 042 episode without outlier are rolled up 399 FULL 043X All revenue code lines Total Part A and Part B occupational therapy visit count during where the first three positions 043 full episode without outlier are rolled up 399 FULL 044X All revenue code lines Total Part A and Part B occupational therapy visit count during where the first three positions 044 full episode without outlier are rolled up 399 FULL 055X All revenue code lines Total Part A and Part B visit count related to nursing services where the first three positions 055 during full episode without outlier are rolled up 399 FULL 056X All revenue code lines Total Part A and Part B visit count related to med soc serv where the first three positions 056 during full episode without outlier are rolled up User Manual February 2009 Version No 2 0 Report Data B 141 Provider Statistical and Reimbursement System
52. payments made under the Prospective Payment System 118 TOTAL OPERATI NG PAYMENTS This is the sum of the operating amounts for HSP FSP outlier DSH LI P IME teaching adjustment new technology IPF ECT and exception payments 118 HOSPITAL SPECIFIC This is the hospital specific portion of the PPS payment for capital The field will be zero for providers paid based on the hold harmless old capital or the hold harmless 100 percent federal method and for new hospitals during their first two years of operation 118 FEDERAL SPECIFIC This field includes the federal portion of the PPS payment for capital This field will also include the new capital amount for hospitals paid under the hold harmless old capital method 118 OUTLIER This field will show the outlier portion of the PPS payment for capital User Manual February 2009 Version No 2 0 Report Data B 5 Provider Statistical and Reimbursement System Report Type Data Element Description 118 HOLD HARMLESS This field shows the hold harmless amount paid for old capital based on the hold harmless old capital method 118 DSH This is the disproportionate share portion of the PPS capital payment 118 INDIRECT MEDI CAL EDUCATION This is the indirect medical education adjustment payment to PPS teaching hospitals applicable to PPS capital payments 118 EXCEPTI ONS This is the per di
53. provisions 82P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 83P CLAIMS Currently this field has no cost report usage 83P UNITS The number of units applicable to each revenue code 83P CHARGES The charges applicable to each revenue code 83P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 83P DESCRIPTI ON The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 83P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 83P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 83P OUTLIER The outlier portion of the OPPS payment for the APC 83P GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 83P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 83P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 83P COINSURANCE The actual coinsurance amount from the paid claim record 83P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in t
54. range of when the Provider owned the child Error Warning Message Warning W008 Service dates requested do not coincide with requestor access rights for Provider ID These dates will be modified on the Confirm Report Request screen to reflect valid access dates Do you wish to Continue ID W008 C 5 Summary Report Request Select Report Format The Summary Report Request Select Report Format page error messages are presented in the following table Exhibit C 5 Summary Report Request Select Report Format Page Error Messages Form Field User Type Validation Error Message ID CSV Radio All If the PDF radio button is Error E046 No report format E046 Button not selected this must be was selected Please choose a selected report format before continuing PDF Radio All If the CSV radio button is Error E046 No report format E046 Button not selected this must be was selected Please choose a selected report format before continuing CSV Format All If the Report 1000 was Warning W009 The 1000 W009 Selected selected from the Select report will not generate in Report s screen the PDF CSV format Do you wish to format should be selected continue PDF amp CSV All If the Report 1000 was Warning W009 The 1000 W009 Format Selected selected from the Select report will not generate in Report s screen the PDF CSV format Do you wish to format sh
55. where the first three positions 056 are rolled up episode User Manual February 2009 Version No 2 0 Report Data B 148 Provider Statistical and Reimbursement System Report Type Data Element Description 399 LUPA 057X All revenue code lines Total covered charges related to home health aide serv during where the first three positions 057 LUPA episode are rolled up 399 LUPA 058X All revenue code lines Part B other visits where the first three positions 058 are rolled up 399 LUPA 059X All revenue code lines Total visit covered charges for various disciplines for LUPA where the first three positions 059 episode are rolled up 399 LUPA 060X All revenue code lines Part B oxygen charges with outlier where the first three positions 060 are rolled up 399 LUPA 062X All revenue code lines Part B medical supplies charges with outlier where the first three positions 062 are rolled up 399 LUPA 0623 Displays by itself Part B surgical dressings charges with outlier 399 LUPA All other Rev Codes display as All other Part B revenue code charges they come in on the claim they do not roll up 399 PEP 0023 Does not display These fields are not populated on this report 399 PEP 027X All revenue code lines Part B medical supplies charges with outlier where the first three positions 027 excluding 0274 are rolled up 399 PE
56. where the first three positions 056 are rolled up 329 SCIC PEP 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 SCIC PEP 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 SCIC PEP 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 SCIC PEP 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 SCIC PEP 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 SCIC PEP 0623 Displays by itself These fields are not populated on this report 329 SCIC PEP All other Rev Codes display These fields are not populated on this report as they come in on the claim they do not roll up 329 SCIC 0023 Does not display These fields are not populated on this report 329 SCIC 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 SCIC 0274 Displays by itself These fields are not populated on this report 329 SCIC 029X All revenue codes lines These fields are not populated on this report where the first three positions
57. 01 05 INPATIENT FEE REIMBURSED Report OD44203 Report Run Date 02 01 07 THESE ITEMS ARE NOT TO BE INCLUDED ON THE MEDICARE COST REPORT Report Type 115 Provider FYE 12 31 Provider Number T00007 PETERBORO GENERAL HOSPITAL SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 04 12 31 04 No Data Requested No Data Requested No Data Requested STATISTIC SECTION I CLAIMS 0 CHARGE SECTION REV CODE DESCRIPTION UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES 0636 DRUGS DETAIL CODE 39 8 002 41 TOTAL COVERED CHARGES 39 8 002 41 REIMBURSEMENT SECTION PAYMENT GROSS REIMBURSEMENT 37 05 LESS CASH DEDUCTIBLE 0 00 BLOOD DEDUCTIBLE 0 00 COINSURANCE 0 00 NET MSP PAYMENTS 0 00 NET REIMBURSEMENT 37 05 ADDITIONAL INFORMATION SECTION CLAIM INTEREST PAYMENTS 0 00 Feb 1 2007 1 7 53 34 PM User Manual Inpatient Reports February 2009 Version No 2 0 4 11 Exhibit 4 10 Provider Statistical and Reimbursement System Inpatient 115 Payment Reconciliation Detail Report Template First Page Program ID REDESIGN Service Month End 02 23 04 Report Run Date 02 07 07 Provider FYE 12 21 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PAYMENT RECONCILIATION REPORT INPATIENT FEE REIMBURSED Provider Number 100007 PETERBORO GENERAL HOSPITAL Patet Ne DCN Pent Cati Med Rcr i HC Nume Recot Dt Paid Ot Service From Service Thru Patet Nan DCN Pant Cata amp Med Ro
58. 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 13P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 13P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 13P OUTLIER The outlier portion of the OPPS payment for the APC 13P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 13P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 13P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 13P COINSURANCE The actual coinsurance amount from the paid claim record 13P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 13P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 13P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 13P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial
59. 056X All revenue code lines Total covered charges related to med soc serv during SCIC where the first three positions 056 only episode are rolled up User Manual February 2009 Version No 2 0 Report Data B 151 Provider Statistical and Reimbursement System Report Type Data Element Description 399 SCIC 057X All revenue code lines Total covered charges related to home health aide services where the first three positions 057 during SCIC only episode are rolled up 399 SCIC 058X All revenue code lines Part B other visits where the first three positions 058 are rolled up 399 SCIC 059X All revenue code lines Total visit covered charges for various disciplines for SCIC where the first three positions 059 only episode are rolled up 399 SCIC 060X All revenue code lines Part B Oxygen charges with outlier where the first three positions 060 are rolled up 399 SCIC 062X All revenue code lines Part B Med Supplies charges with outlier where the first three positions 062 are rolled up 399 SCIC 0623 Displays by itself Part B Surgical Dressings charges with outlier 399 SCIC All other Rev Codes display as All other Part B Revenue Code Charges they come in on the claim they do not roll up 399 TOTAL 0023 Does not display These fields are not populated on this report 399 TOTAL 027X All revenue code lines Part B medical supplies cha
60. 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 TO00 T999 M300 M399 R300 R399 No 118 Inpatient Part A Managed Care Inpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 TO00 T999 M300 M399 R300 R399 Yes 119 Inpatient PPS Interim Bills Inpatient Acute Hospital 0001 0999 No 12A Inpatient Part B MSP LCC Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 No User Manual February 2009 Version No 2 0 Report Details A 2 Provider Statistical and Reimbursement System Report Type Report Name Service Category Provider Type s Provider Number Range Cost Report Yes No 12P Inpatient Part B OPPS Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 12Z Inpatient Ambulance Blend Effective 04 01 02 Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 120 Inpatient Part B Cost Reimbursed Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 122 Inpatient Part B Vac
61. 11T TOTAL ACCOMODATIONS This category may include provider liable days that are non covered days This category may be used to prorate the Medicare Days field for cost reporting purposes 11T TOTAL ANCILLARY All Medicare covered charges associated with revenue codes designated as ancillary 11T TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as routine and ancillary 11T HOSPITAL SPECIFIC This line plus any federal specific amounts are the total DRG amounts other than outlier 11T FEDERAL SPECIFIC This line plus any hospital specific amounts are the total DRG amounts other than outlier 11T OUTLIER Summarizes cost outlier payments Value code 17 made under the Prospective Payment System User Manual February 2009 Version No 2 0 Report Data B 21 Provider Statistical and Reimbursement System Report Type Data Element Description 11T DSH LIP The DSH LIP amount value code 18 shown on the PS amp R report represents interim payments calculated by the PPS Pricer program For cost reporting purposes the DSH LIP amount must be recomputed for qualifying hospitals 11T IME TEACHING AD Indirect medical education Teaching adjustment Value Code 19 amount shown on the PS amp R are estimated payments made on a bill by bill basis by the PPS Pricer program For cost reporting purposes the amount must be recomputed 11T NEW TECHNOLOG
62. 2 0 Report Data B 161 Provider Statistical and Reimbursement System Report Type Data Element Description 399 SCIC OTHER ADJ USTMENTS Part B Other Adjust for SCIC 399 SCIC NET REIMBURSEMENT Part B Net Reimb for SCIC 399 SCIC CLAIM INTEREST PAYMENTS Part B Claim Interest Payments for SCIC 399 TOTAL HIPPS REIMBURSEMENT Total Part B of Episodes w o outlier WITHOUT OUTLIER 399 TOTAL EPISODES WITH OUTLIER Total Part B HIPPS Reimb w o outlier 399 TOTAL HIPPS REIMBURSEMENT WITH Total Part B of Episodes with outlier OUTLIER 399 TOTAL OUTLI ER REI MBURSEMENTS Total Part B HIPPS Reimb with outlier 399 TOTAL PROSTHETI C ORTHOTIC Total P amp O for full episodes DEVICES 399 TOTAL DME Total DME for full episodes 399 TOTAL OXYGEN Oxygen for full episodes 399 TOTAL OTHER FEE REIMBURSEMENTS Total other fee reimbursements 399 TOTAL GROSS REIMBURSEMENT Total Part B gross reimbursement 399 TOTAL DEDUCTI BLES Total Part B deductible 399 TOTAL COINSURANCE Total coinsurance 399 TOTAL NET MSP PAYMENTS Total MSP 399 TOTAL MSP RECONCILI ATI ON Net MSP for Part B 399 TOTAL OTHER ADJUSTMENTS Total other adjustments 399 TOTAL NET REIMBURSEMENT Total net reimbursement 399 TOTAL CLAIM INTEREST PAYMENTS Total Part B claim interest payments User Manual February 2009 Version No 2 0 Report Data B 162 Provider Statistical and Reimburse
63. 2 6 Inpatient Part A Managed Care 118 Inpatient Part A Managed Care 118 report summarizes services billed under Part A for Medicare managed care patients for purposes of receiving reimbursement for direct graduate medical education DGME and indirect medical education IME The items reported on the Inpatient Part A Managed Care 118 report are not to be included on the Medicare Cost Report 4 2 7 Inpatient Rehabilitation Part A PPS 11R The Inpatient Rehabilitation Part A PPS 11R report summarizes Inpatient Part A hospital services reimbursed under the Inpatient Rehabilitation Facility Prospective Payment System The items reported on the Inpatient Rehabilitation Part A PPS 11R report are included on the Medicare Cost Report 4 2 8 Inpatient PPS Interim Bills 119 The Inpatient PPS Interim Bills 119 report summarizes Inpatient Part A hospital services reimbursed under the Inpatient Prospective Payment System PPS that have been billed on an interim basis that is bill frequency code of 2 or 3 The items reported on the Inpatient PPS Interim Bills 119 report are not to be included on the Medicare Cost Report 4 2 9 Inpatient PartA 110 The Inpatient Part A 110 report summarizes Inpatient Part A hospital services including services reimbursed under cost Tax Equity and Fiscal Responsibility Act of 1982 TEFRA and the Inpatient Prospective Payments System PPS The items reported on the Inp
64. 236 649 04 9 702 295 791 74 0 0 00 0 0 00 TOTAL COVERED CHARGES 381 148 04 585 722 74 0 00 0 00 REIMBURSEMENT SECTION PAYMENT GROSS REIMBURSEMENT 190 570 00 255 850 00 0 00 0 00 CASH DEDUCTIBLE 0 00 0 00 0 00 0 00 BLOOD DEDUCTIBLE 0 00 0 00 0 00 0 00 COINSURANCE 109 50 0 00 0 00 0 00 NET MSP PAYMENTS 0 00 0 00 0 00 0 00 NET REIMBURSEMENT 190 460 50 255 850 00 0 00 0 00 ADDITIONAL INFORMATION SECTION CALCULATED NET REIMB FOR PIP 0 00 0 00 0 00 0 00 ACTUAL CLAIM PAYMENTS FOR PIP 0 00 0 00 0 00 0 00 CLAIM INTEREST PAYMENTS 16 21 0 00 0 00 0 00 Feb 5 2007 2 9 51 23 AM User Manual Inpatient Reports February 2009 Version No 2 0 4 17 Exhibit 4 14 Program ID REDESIGN Service Month End 02 23 04 Report Run Date 02 07 07 Provider FYE 12 31 Provider Number T0Z300 SNOW BIRD HOSPITAL Patet Nec DCN Pint Cati Med Rcrd amp HIC Nume Recpt Dt Paid Dt Service Frome Service Thru Mad Days Patet Nec DCN Pant Cagri d Med Rerd s HIC Numc Recot Dt Paid Dt Service From Service Thru Med Days Monthly Totals for SNOW BIRD HOSPITAL for service month end 2 29 04 Med Days 35 Feb 7 2007 Provider Statistical and Reimbursement System Inpatient 18x and 21x Payment Reconciliation Detail Report Template First Page sia 20473583433805 1832000200200 633000060000 4835528554 02 23 04 04 02 04 01 21 04 02 11 04 M 04 21 04 02 13 04 02 27 0
65. 832 835 834 83P 83Z PHI Excluded No Format csv Paid Dates 01 01 2006 to 10 01 2006 Contact Info Primary First Name jason Last Name jones zl Phone 804 555 1212 E mail jason jones parrothead com Fax Reason for Request annual reporting Service Periods Provider ID Period 1 Period 2 Period 3 Period 4 00028 From 01 01 2006 From 04 01 2006 From 07 01 2006 From 10 01 2006 To 03 31 2006 To 06 30 2006 To 09 30 2006 To 12 31 2006 zi Note This request will generate up to 7 Detail Report s Data does not exist for the Provider Report combinations listed as No Data Available for the chosen Service Paid Date Periods therefore no report s will be generated for these providers reports I Save Request as Favorite Favorite Name 50 Char TRTESTI 7 D 9904 Back Save A summary or detail report can be viewed once the report status is Complete To open a report from the Summary Report Inbox click the PDF or CSV icon corresponding to the desired report based on the type of report format that was requested To refresh the contents of the inbox click Refresh If a report is selected from the Summary Report Inbox or Detail Report Inbox the selected report opens in a new Browser window with a report summary page displayed The first page of the report provides a cover page identifying the total number of pages for each provider number and report contained in the file Click
66. Apply contain only numeric Date s entry contains a button characters non numeric character or is not in MM DD YYYY format E069 Change Periods with All All date field entries must be Error E069 Service Specific Dates Apply in MM DD YYYY format Date s entry contains a button non numeric character or is not in MM DD YYYY format E081 Filter by FYE Date FI MAC If box is checked a month Error E081 Filter by Checkbox Parent must be selected from the FYE Date chosen but Provider Month drop down menu month not selected E092 Service Period From All Entry must be greater than Error E092 Service Date the previous Service Period To Date this assures chronological service periods and that there is no overlapping service periods Periods overlap and or are not chronological for Provider ID 5 User Manual February 2009 Version No 2 0 Error Messages C 37 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message E092 Service Period From All Entry must be greater than Error E092 Service Dates in Selected the previous Service Period Periods overlap and or Service Periods To Date this assures are not chronological for Table chronological service periods Provider ID ID 5 and that there are no overlapping service periods E092 Service Period To All Entry must be less than the Error E092 Service Dates next Se
67. B Fee Reimbursed 345 report shows covered charges and reimbursement by revenue code for fee reimbursed services The items reported on the Home Health Part B Fee Reimbursed 345 report are not to be included on the Medicare Cost Report 5 7 7 Federally Qualified Health Center Fee Reimbursed 735 The Federally Qualified Health Center Fee Reimbursed 735 report shows covered charges and reimbursement by revenue code for fee reimbursed services The items reported on the Federally Qualified Health Center Fee Reimbursed 735 report are not to be included on the Medicare Cost Report 5 7 8 Rehabilitation Facility Fee Reimbursed 745 The Rehabilitation Facility Fee Reimbursed 745 report shows covered charges and reimbursement by revenue code for fee reimbursed services The items reported on the Rehabilitation Facility Fee Reimbursed 745 report are not to be included on the Medicare Cost Report 5 7 9 Comprehensive Outpatient Rehabilitation Facilities Fee Reimbursed 755 The Comprehensive Outpatient Rehabilitation Facilities Fee Reimbursed 755 report shows covered charges and reimbursement by revenue code for fee reimbursed services The items reported on the User Manual Outpatient Reports February 2009 Version No 2 0 5 33 Provider Statistical and Reimbursement System Comprehensive Outpatient Rehabilitation Facilities Fee Reimbursed 755 report are not to be included on the Medicare Cos
68. B 121 Provider Statistical and Reimbursement System Report Type Data Element Description 339 FULL 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 FULL 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 FULL 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 FULL 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 FULL 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 FULL 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 FULL 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 FULL 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 FULL 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 FULL 062X All revenue code lines These
69. Blend Provider Summary Report Template Program ID REDESIGN Paid Dates 02 01 04 THRU 10 01 05 Report Run Date 02 01 07 Provider FYE 12 31 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PROVIDER SUMMARY REPORT OUTPATIENT AMBULANCE BLEND EFFECTIVE 04 01 02 Provider Number 100007 FETERBORO GENERAL HOSPITAL STATISTIC SECTION CLAIMS TOTAL AMBUIANCE TRIPS TOTAL AMBUIANCE MILES TOTAL GROSS FEE SCHEDULE AMT CHARGE SECTION REV CODE DESCRIPTION 0540 AMBULANCE TOTAL COVERED CHARGES REIMBURSEMENT SECTION GROSS REIMBURSEMENT LESS CASH DEDUCTIBLE BLOOD DEDUCTIBLE COINSURANCE NET MSP PAYMENTS PSYCH REDUCTION NET REIMBURSEMENT ADDITIONAL INFORMATION SECTION CLAIM INTEREST PAYMENTS Feb 1 2007 SERVICES FOR PERIOD 01 01 04 12 21 04 s UNITS CHARGES GROSS FEE AMT 9 20 142 00 1 557 63 103 2 461 00 211 46 51 769 09 UNITS CHARGES 32 603 00 na 32 603 00 14 005 11 0 00 0 00 4 731 12 0 00 0 00 9 273 99 SERVICES FOR PERIOD No Data Requested CHARGES GROSS FEE AMT UNITS SERVICES FOR PERIOD No Data Requested CHARGES GROSS FEE AMT CHARGES Page 7 Report 0044203 Report Type 132 SERVICES FOR PERIOD No Data Requested UNITS CHARGES GROSS FEE AMT 0 00 7 57 44 PM User Manual February 2009 Version No 2 0 Outpatient Reports 5 23 Provider Statistical and Reimbursement System Exhibit 5 11 Outpatient xxZ Ambulance Blend Payment Reconcilia
70. Button button or By Report Type were selected radio button is not clicked this radio button must be clicked E034 By Report Type All If By Service Type radio Error E034 No reports Radio Button button or By Report Group were selected radio button is not clicked this radio button must be clicked E034 By Service Type All If By Report Type radio Error E034 No reports Radio Button button or By Report were selected Number radio button is not clicked this radio button must be clicked E036 By Report Group All If radio button is clicked at Error E036 By Report Radio Button least one report group must group option selected be selected but no report group s chosen E037 By Report Type All If radio button is clicked at Error E037 By Report Radio Button least one report type must Type option selected be selected but no report type s chosen E038 Service Period From All Field must not be null Error E038 Service Date Date s entry for Provider ID 5 contains a non numeric character or is not in MM DD YYYY format E038 Service Period From All Only numeric characters Error E038 Service Date Date s entry for Provider lt ID 5 contains a non numeric character or is not in MM DD YYYY format E038 Service Period From All Entry must be in Error E038 Service Date MM DD YYYY format Date s entry for Provider lt ID 5 contains a non nume
71. COST REIMBURSED Report OD44203 Report Run Date 02 05 07 Report Type 130 Provider FYE 09 30 Provider Number T50100 CHARITY HOUSE MEMORIAL HOSPITAL SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 04 12 31 04 01 01 05 12 31 05 01 01 06 12 31 06 No Data Requested STATISTIC SECTION CLAIMS 0 2 43 CHARGE SECTION REVCODE DESCRIPTION UNITS CHARGE UNITS CHARGES UNITS CHARGES UNITS CHARGES 0260 IV THERAPY 0 0 00 0 0 00 0 0 00 0278 SUPPLY IMPLANTS 0 0 00 0 0 00 1 7 050 00 0300 LABORATORY or LAB 0 0 00 2 0 00 52 0 00 0301 LAB CHEMISTRY 0 0 00 0 0 00 5 0 00 0420 PHYSICAL THERP 0 0 00 0 0 00 0 0 00 0480 CARDIOLOGY 0 0 00 0 0 00 0 0 00 TOTAL COVERED CHARGES o 0 00 2 0 00 58 7 050 00 REIMBURSEMENT SECTION GROSS REIMBURSEMENT 0 00 0 00 2 567 50 LESS CASH DEDUCTIBLE 0 00 0 00 0 00 BLOOD DEDUCTIBLE 0 00 0 00 0 00 COINSURANCE 0 00 0 00 1 410 00 NET MSP PAYMENTS 0 00 0 00 0 00 PSYCH REDUCTION 0 00 0 00 0 00 NET REIMBURSEMENT 0 00 0 00 1 057 50 ADDITIONAL INFORMATION SECTION CLAIM INTEREST PAYMENTS 0 00 0 00 0 00 Feb 5 2007 1 10 12 25 AM User Manual February 2009 Version No 2 0 Outpatient Reports 5 35 Provider Statistical and Reimbursement System Exhibit 5 18 Outpatient xxO All Other Payment Reconciliation Report Template First Page Program ID REDESIGN Service Month End 05 31 04 Report Run Date 02 07 07 Provider FYE 09 30 Pro
72. Cost Report 4 3 4 SNF Inpatient Part A PPS 210 The SNF Inpatient Part A PPS 210 report summarizes skilled nursing facility Inpatient Part B services The items reported on the SNF Inpatient Part A PPS 210 report are included on the Medicare Cost Report User Manual Inpatient Reports February 2009 Version No 2 0 4 20 5 Provider Statistical and Reimbursement System Outpatient Reports The PS amp R System consists of a number of outpatient reports that are based on standardized outpatient report templates The template categories and the corresponding reports are e 72x Hospital Based or Independent Renal Dialysis Center Report Template Hospital Based or Independent Renal Dialysis Center MSP LCC 72A Hospital Based or Independent Renal Dialysis Center Composite Rate Services 720 Hospital Based or Independent Renal Dialysis Center Fee Reimbursed 725 e xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Report Template Inpatient Part B MSP LCC 12A Outpatient All Other MSP LCC 13A Outpatient Other MSP LCC 14A SNF Inpatient Part B MSP LCC 22A SNF Outpatient MSP LCC 23A Home Health Part B MSP LCC 34A Clinic Rural Health MSP LCC 71A Federally Qualified Health Center MSP LCC 73A Rehabilitation Facility MSP LCC 74A Comprehensive Outpatient Rehabilitation Facilities MSP LCC 75A Community Mental Health Center MSP LCC 76A
73. Cost Report 5 7 2 Outpatient Fee Reimbursed 135 The Outpatient Fee Reimbursed 135 report shows covered charges and reimbursement by revenue code for fee reimbursed services for hospital outpatient services The items reported on the Outpatient Fee Reimbursed 135 report are not to be included on the Medicare Cost Report 5 7 3 Outpatient Other Fee Reimbursed 145 The Outpatient Other Fee Reimbursed 145 report shows covered charges and reimbursement by revenue code for fee reimbursed services for other outpatient services The items reported on the Outpatient Other Fee Reimbursed 145 report are not to be included on the Medicare Cost Report 5 7 4 SNF Inpatient Fee Reimbursed 225 The SNF Inpatient Fee Reimbursed 225 report shows covered charges and reimbursement by revenue code for fee reimbursed services for inpatient skilled nursing facility services The items reported on the SNF Inpatient Fee Reimbursed 225 report are not to be included on the Medicare Cost Report 5 7 5 SNF Outpatient Fee Reimbursed 235 The SNF Outpatient Fee Reimbursed 235 report shows covered charges and reimbursement by revenue code for fee reimbursed services for outpatient skilled nursing facility services The items reported on the SNF Outpatient Fee Reimbursed 235 report are not to be included on the Medicare Cost Report 5 7 6 Home Health Part B Fee Reimbursed 345 The Home Health Part
74. Date previous Service Period To selected non consecutive W003 or Date this checks to see if service periods for W004 the service periods are Provider ID 5 This consecutive will exclude cost report data from the results Do you wish to continue Clicking the Continue button will bring user to next request page clicking the Back button will bring user back to the dates page and allow them to make any changes User Manual February 2009 Version No 2 0 Error Messages C 44 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message W005 FI MAC Provider FI MAC Admin If a user wants to change Warning Requests Back providers warning message The Selected Report button on the 2 must appear Types will be lost if the Select Reports provider selection is Screen changed f provider selection is changed the report types needs to be reselected Do you wish to go back to the Provider Selection List W006 FI MAC Provider FI MAC Admin If Providers have been Warning Requests Select changed by the FI MAC The original requestor s Provider s Screen admin display warning provider selection has message after the admin been changed clicks Continue from the The selected provider s Select Provider s screen may not belong to the requestor Do you wish to continue W007 FI MAC Provider FI MAC Admin If Service Period Dates ha
75. E001 Select Paid To Date All Month Day and Year values Error E001 Paid To Date must be valid entry contains an invalid month day and or year E001 Service Period From All Month Day and Year values Error E001 Service Date Date must be valid entry for Provider ID 5 contains an invalid month day and or year E001 Service Period From All Month Day and Year values Error E001 Service Date Dates in Selected Service Periods Table must be valid entry for Provider ID 5 contains an invalid month day and or year User Manual February 2009 Version No 2 0 Error Messages C 30 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message E001 Service Period To All Month Day and Year values Error E001 Service Dates must be valid Date s entry for Provider ID 5 contains an invalid month day and or year E001 Service Period To All Month Day and Year values Error E001 Service Dates in Selected must be valid Date s entry for Provider Service Periods ID 5 contains an Table invalid month day and or year E007 Paid Date To Date All Entry must be less than or Error E007 Paid To equal to the default date date must be on or before CMS User the latest paid default dates date from any paid claim file FI MAC User the latest paid date from a paid claim fi
76. E183 Batch Job Submit Batch Job Summary Batch Job Submit Failed amp arg1 System Error PS amp R SDK Error Error submitting Error E185 Error while trying to E185 Batch Job Submit Batch Job Summary Batch Job Submit Failed System Error PS amp R Error while preparing to find Error E186 Error preparing to E186 FI find FI amp arg1 System Error PS amp R Cannot find the FI with the Error E187 FI not found with key E187 specified key amp arg1 System Error PS amp R Error while retrieving FI Error E188 Error retrieving FI E188 amp arg1 System Error PS amp R Error when closing connection Error E189 Error closing E189 connection amp arg1 System Error PS amp R Error while preparing to find Error E190 Error preparing to E190 load control records find load control records amp arg1 System Error PS amp R Error retrieving load control Error E191 Error retrieving load E191 reports control records amp arg1 System Error PS amp R Error while preparing to find Error E192 Error preparing to E192 last available paid date find last avail paid date records records amp arg1 System Error PS amp R Cannot find the last available Error E193 No last avail paid E193 paid date for the specified FI date found for FI amp arg1 System Error PS amp R Error retrieving the last Error E194 Error retrieving last E194 available paid date records avail paid date records amp arg1 System Error PS amp R Error while preparing to get Error E19
77. Expired PS amp R Session will expire after 20 Error E010 Session E010A Session min of inactivity expired Please login before continuing E014 Application Down PS amp R Cognos ReportNet is down Error E014 Application and therefore requesting down Not able to make reports is not possible ReportNet connection at this point E015 Login Null PS amp R A User ID and Password Error E015 Invalid user must be entered to login to ID and or password the PS amp R system E015 Login Password PS amp R Password must be valid for Error E015 Invalid user the User ID ID and or password E015 Login User ID PS amp R User ID must be valid Error E015 Invalid user ID and or password E024 All Providers Parent If By Provider Type or By Error E024 Please select Provider Provider Number radio provider s button is not clicked this radio button must be clicked E024 By Provider Number CMS FI MAC If By Provider Type within Error E024 Please select Radio Button Parent Contractor CMS users only provider s Provider or By Provider Type or All Providers Parent Provider users only radio button is not clicked this radio button must be clicked E024 By Provider Type CMS If By Provider Number Error E024 Please select Within Contractor radio button is not clicked provider s Radio Button this radio button must be clicked E024 By Provider Type FI MAC If By Provider Number Error E024 Please select
78. ID TRTEST17 5 9900 2 Your Request Name ffATESTI7 S 9900 oS S 50 Char Requested Provider s T75237 Requested Report s 210 21A 220 222 225 224 22P 22Z 230 232 235 23A 23P 23Z 24P 1000 No Data Available T75237 210 214 220 222 225 224 22P 222 230 232 235 23A 23P 23Z 24P Format PDF amp CSV Files Separated by Provider No Paid Dates Include all Paid Dates available at time of report generation Service Periods Provider Period 1 Period 2 Period 3 Period 4 Exclude ID Provider e From 01 01 2006 From 01 01 2007 E 01 01 2008 From 01 01 2009 E To 12 31 2006 To 12 31 2007 To 12 31 2008 To 12 31 2009 si Note This request will generate up to 1 Summary Report s The 1000 and or 399 report s may be blank if the component reports have no data for the dates requested Data does not exist for the Provider Report combinations listed as No Data Available for the chosen Service Paid Date Periods therefore no report s will be generated for these providers reports T Save Request as Favorite Back 10 Type the request name or accept the default name The request name can be up to 50 characters Select the Exclude check box to exclude any providers from the report s To save the request to your Favorite Requests list select the Save Request as Favorite check box Type the request name or accept the default name Up to 100 favorite report req
79. Include 110 DRG Section check box in the exhibit above To clear a check box the user clicks the check box again removing the check mark 2 3 3 Drop Down List Drop down lists allow a user to choose one item from a list of items The following exhibit provides an example of a drop down list demonstrating both collapsed and expanded views of the drop down list User Manual System Overview and Common Features February 2009 Version No 1 2 10 Provider Statistical and Reimbursement System Exhibit 2 11 Drop Down List Collapsed and Expanded A Drop Down List Collapsed B Drop Down List Expanded All m All All Inpatient Outpatient Part A of the exhibit above shows a collapsed drop down list showing how the control appears by default Part B of the exhibit shows an expanded drop down list listing all of the items that are available from which the user chooses To view the drop down list the user must click the down arrow exi on the right hand side of the drop down list Once the user clicks the down arrow the control displays the list of available items To choose an item the user must click the item s name Once the user clicks an item the drop down menu returns to the collapsed position and displays the selected item 2 3 4 List Box A List Box enables a user to choose one item or multiple items from a list The following exhibit provides an example of a list box Exhibit 2 12
80. LUPA All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 PEP 0023 Does not display These fields are not populated on this report 329 PEP 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 PEP 0274 Displays by itself These fields are not populated on this report 329 PEP 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 PEP 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 PEP 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 PEP 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 PEP 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 102 Provider Statistical and Reimbursement System Report Type Data Element Description 329 PEP 056X All revenue code lines These fields are not populated on this
81. MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 22P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 22P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 22P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 48 Provider Statistical and Reimbursement System Report Type Data Element Description 22P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 22P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 23P CLAIMS Currently this field has no cost report usage 23P UNITS The number of units applicable to each revenue code 23P CHARGES The charges applicable to each revenue code 23P REV CODE E
82. Manual Table of Contents February 2009 Version No 2 0 vii Provider Statistical and Reimbursement System Table of Exhibits Exhibit 2 1 Exhibit 2 2 Exhibit 2 3 Exhibit 2 4 Exhibit 2 5 Exhibit 2 6 Exhibit 2 7 Exhibit 2 8 Exhibit 2 9 Exhibit 2 10 Exhibit 2 11 Exhibit 2 12 Exhibit 2 13 Exhibit 2 14 Table 2 1 Exhibit 4 1 Exhibit 4 2 Exhibit 4 3 Exhibit 4 4 Exhibit 4 5 Exhibit 4 6 Exhibit 4 7 Exhibit 4 8 Exhibit 4 9 Page Header cede du e puede tte ET ede Mev EE DR CERER SERT DEMO 2 2 Page Header Fieldsi uirae ne anar eee eee eee ee eese sense menn ense 2 2 Centers for Medicare and Medicaid Services Website 0a naasa 2 4 Site Maps Page iid rre thaw bes Er PEREE P EAR ka Kapag kappa deen da man 2 5 Announcements Page ccccee cece eee e eens eee eens nee eme E emen enne enne 2 6 OMM Kaka ATA NAGANA edu KTA AN PANDA ANT KANA 2 7 Online Help Example c ccc eee e cece eee mmm see en enm mene 2 8 le 2 3 o mr 2 9 Radio BUttons niic ag eo d ts etes ee ies e ds 2 10 Check BOX6S 2 icu eee etr ede eee teet totu i ie UD eR Enn 2 10 Drop Down List Collapsed and Expanded 2 aasa 2 11 Eist BOX na PE 2 11 Transfer List BOX xd a ANA aa tan 2 12 Calenda EE 2 12 Useful IE KeystrokeS sssssssssssrrrrssererrrrssrrrrrresririrrnnsrrrrnnnererrnnnenet 2 15 Inpatient Report Header aaa cece ak KGG ANNA eme sehen memes nnn 4 1 Inpatient Report Header Fields
83. Medicare Administrative Contractors 1 12 As a provider why am I not allowed to get detail reports sent to my inbox 1 13 Are there limits to how many Summary PS amp R reports I can run at one time 1 14 Is there a size limitation for individual Detail PS amp R requests 1 15 How do I get PS8R reports for my company if I am a Home Office 2 2 1 5 Help The Help hyperlink when selected opens the PS amp R System online Help Online Help opens in a new Browser window The following exhibit displays an example of online Help displaying the Introduction topic User Manual System Overview and Common Features February 2009 Version No 1 2 7 Provider Statistical and Reimbursement System Exhibit 2 7 Online Help Example teres s Ind 3 Se Fsearch GO Powered By LUTTE M is Introduction Outpatient Reports o Consolidation Reports The Provider Statistical and Reimbursement PS amp R system produces a variety of reports for Fiscal Intermediaries FIs Medicare Administrative Contractors MACs the Centers for Medicare and Medicaid Services CMS and Medicare Part A providers These reports accumulate statistical and payment data for hospitals hospital complexes skilled nursing facilities hospices end stage renal disease facilities comprehensive outpatient rehabilitation facilities and home health agencies The PS amp R system is comprised of many web pages that allow FI MAC users CMS users and Medic
84. Medicare Part A providers to request the generation of summary and detail reports for inpatient and outpatient services The reports that can be generated by a specific user are determined by the user s access authority assigned to the user ID The PS amp R system provides the following Users can define report selection criteria such as the report groups report types service types and date ranges to include in the reports using the graphical user interface e All providers can request summary reports directly in the system e Providers can submit online requests for detail reports The provider s FI MAC then either approves or denies the request If the request is approved the FI MAC sends the reports to the provider on acceptable media e FI MACS can request detail reports directly in the system The FI MAC s PS amp R administrative representative then either approves or denies the request If the request is approved the FI MAC administrative representative routes the reports to the requesting provider e Reduces the time to complete cost reports by providing a central repository for all claims data e Provides an efficient means for flexible definition of business rules that allow changes to the business rules without changing core software 1 1 Document Conventions The following conventions have been used throughout this document e To represent text that is dynamic the text is enclosed in angle brackets lt gt as follo
85. Outpatient Rehabilitation Facilities Vaccine Part B 100 Reasonable Cost 752 The Comprehensive Outpatient Rehabilitation Facilities Vaccine Part B 100 Reasonable Cost 752 report summarizes vaccine services provided by Comprehensive Outpatient Rehabilitation facilities The items reported on the Comprehensive Outpatient Rehabilitation Facilities Vaccine Part B 10096 Reasonable Cost 752 report are included on the Medicare Cost Report 5 6 11 Community Mental Health Center Vaccine Part B 100 Reasonable Cost 762 The Community Mental Health Center Vaccine Part B 10096 Reasonable Cost 762 report summarizes vaccine services provided by Community Health Centers The items reported on the Community Mental Health Center Vaccine Part B 100 Reasonable Cost 762 report are included on the Medicare Cost Report 5 6 12 ASC and ASC Fee Schedule Vaccine Part B 10096 Reasonable Cost 832 The ASC and ASC Fee Schedule Vaccine Part B 10096 Reasonable Cost 832 report summarizes vaccine services provided by Ambulatory Surgical Surgery Centers reimbursed on a reasonable cost basis The items reported on the ASC and ASC Fee Schedule Vaccine Part B 10096 Reasonable Cost 832 report are included on the Medicare Cost Report 5 6 13 Critical Access Hospital Vaccines Part B 100 Reasonable Cost 852 The Critical Access Hospital Vaccines Part B 10096 Reasonable Cost 852 report summarizes vaccine s
86. Part B NET reimbursement for SCIC only 329 TOTAL HIPPS REIMBURSEMENT Total Part B HIPPS reimbursement without outlier WITHOUT OUTLIER 329 TOTAL EPISODES WITH OUTLIER 329 TOTAL HIPPS REIMBURSEMENT WITH This is the total Part B number of episodes without outlier OUTLIER 329 TOTAL OUTLIER REI MBURSEMENTS This is the total Part B HHPPS reimbursement without outlier 329 TOTAL PROSTHETIC ORTHOTIC This is the total Part B number of episodes with outlier DEVICES 329 TOTAL DME This is Part B HHPPS reimbursement with outlier for SCIC only 329 TOTAL OXYGEN This is Part B oxygen 329 TOTAL OTHER FEE REIMBURSEMENTS This is Part B other fee 329 TOTAL GROSS REI MBURSEMENT This is TOTAL Part B DME 329 TOTAL DEDUCTIBLES This is Part B deductibles 329 TOTAL COINSURANCE This is Part B coinsurance 329 TOTAL NET MSP PAYMENTS This is Part B MSP payments 329 TOTAL MSP RECONCILIATI ON This is Part B MSP reconciliation 329 TOTAL OTHER ADJUSTMENTS This is Part B other adjustments 329 TOTAL NET REIMBURSEMENT This is Part B net reimbursement 329 TOTAL CLAIM INTEREST PAYMENTS Total Part B claim interest payments 339 Rev Code PDF Revenue These fields are not populated on this report Code CSV Column 339 FULL 0023 Does not display These fields are not populated on this report 339 FULL 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up
87. Per a dh 2 12 2 3 7 Command BUttODSs s coca n eee ANA ade ENTE 2 13 2 3 8 Keyboard Shortcuts esses mensem mener 2 13 2 3 9 Special Charactets re NALANG Baa 2 14 2 4 Useful Internet Explorer Keystrokes esses menn 2 15 3 Performing Tasks in the PS amp R neesesieseesee sense na nnam uan uana ananas nnmnnn nna 3 1 3 1 User Preferences La Ee e ERR BANANA ANGAL 3 4 3 1 1 Change Contractor D iet NN KG ee expers atre motu 3 5 3 2 Favorite Requests cce ee eye tuse BG NGALAN dee Eie Tra aTa 3 6 3 3 Request Summary Report3s nennen hene memes eene 3 8 User Manual Table of Contents February 2009 Version No 2 0 i Provider Statistical and Reimbursement System 3 4 Request Detail Reports aaaaana naan kana NGA ANN GANGBANG ANAN KANA NKA KANAN KA KARGA KA NANGAKONG 3 15 3 5 Report INDOK Kina pA Na ceder eda ns Mia ND NANA NN ADA ee 3 24 4 Inpatient ReportsS 2 224 manen aaa nana ANA KANAN A AN AA KANA AN ANNA NANA AN KANAN AN KAA KAANAK Rau assa uuu uasa n 4 1 4 1 Inpatient Report Type Assignment asaaa cece eee eee ee kaa m meer nnns 4 3 All Th Claims Processing KAN NG ene oe E RE SERERE 4 3 4 1 2 18x Claims Processing sssssssssssss II res 4 4 4 1 3 21x Claims Processing ssssssssssssssss I memes eene 4 4 4 1 4 410 Claims Processing ssssssssssssI Ires 4 4 4 2 XIX Report Templat
88. REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 855 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 855 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 855 COINSURANCE The actual coinsurance amount from the paid claim record 855 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance User Manual February 2009 Version No 2 0 Report Data B 86 Provider Statistical and Reimbursement System Report Type Data Element Description 855 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 855 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 720 CLAIMS Currently this field has no cost report usage 720 UNITS Rev Code 821 Cond Code 71 The number of units applicable to each revenue code 720 UNITS Rev Code 821 Cond Code 72 The number of units applicable to each revenue code 720 UNITS Rev Co
89. Reimbursement and the charges for the revenue codes The reimbursements section shows how Net Reimbursement is calculated The additional information section shows Claim Interest MSP Cash Deductible MSP Blood Deductible MSP Coinsurance Standard Overhead Amount and Claim Report Splits The report also provides a monthly totals section that sums the information from the sections above An example of the 831 ASC and ASC Fee Schedule After 12 90 Provider Summary report and the 831 ASC and ASC Fee Schedule After 12 90 Payment Reconciliation detail report follow User Manual Outpatient Reports February 2009 Version No 2 0 5 50 Exhibit 5 28 Outpatient 831 ASC and ASC Fee Schedule After 12 90 Provider Summary Report First Page Provider Statistical and Reimbursement System Program ID REDESIGN Service Month End 11 30 99 Report Run Date 02 19 07 Provider FYE 09 30 Provider Number 100028 PARROTHEAD MEDICAL CENTER Patt Nm WOODM Bill Freq DCN 20449979184603 Trans Type Put Creri e 99700000000 Processor ID Med Rerd 145000000000 HIC Nume 186488514C1 Recpt Dt 03 29 04 Paid Dt 05 03 04 Service From 06 19 00 Service Thru 06 19 00 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Monthly Totals for PARROTHEAD MEDICAL CENTER for service month end 11 30 99 Feb 19 2007 TOTAL Une Stndrd HCPCS Units Charges e Aan Bera Coins MSP Mem Ovthd Rein Amt 34 90 0 00 0 00 696 000
90. Report User Manual Outpatient Reports February 2009 Version No 2 0 5 20 Provider Statistical and Reimbursement System 5 4 8 Clinic Rural Health OPPS 71P The Clinic Rural Health OPPS 71P report captures data from all lines that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the Clinic Rural Health OPPS 71P report are included on the Medicare Cost Report 5 4 9 Federally Qualified Health Center OPPS 73P The Federally Qualified Health Center OPPS 73P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the Federally Qualified Health Center OPPS 73P report are included on the Medicare Cost Report 5 4 10 Rehabilitation Facility OPPS 74P The Rehabilitation Facility OPPS 74P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the Rehabilitation Facility OPPS 74P report are included on the Medicare Cost Report 5 4 11 Comprehens
91. Section but the request is not Section is only applicable Outpatient or All By to HHA Providers and Service Type OR 32x reports 329 and 339 33x xx9 By Report Group OR 329 339 By Report Type E322 Interval Apply All Date field must not be null Error E322 Period 1 Button Start Date contains a non numeric character or is not in MM DD YYYY format E322 Interval Apply All Date field must contain only Error E322 Period 1 Button numeric characters Start Date contains a non numeric character or is not in MM DD YYYY format E322 Interval Apply All Date field entry must be in Error E322 Period 1 Button MM DD YYYY format Start Date contains a non numeric character or is not in MM DD YYYY format E325 Reason for Request FI MAC Non Field must not be null Error E325 No Primary field Admin Reason For Request entered Please enter Primary Reason For Request to proceed E326 By Report Group All If the provider is only given Error E326 The 998 Inpatient Providers access to Inpatient the 998 Report is only applicable only report cannot be selected to outpatient Providers E326 By Service Type All If the provider is only given Error E326 The 998 Inpatient Providers access to Inpatient the 998 Report is only applicable only report cannot be selected to outpatient Providers User Manual February 2009 Version No 2 0 Error Messages C 43 Provide
92. System Error PS amp R Job History is not found for Error E172 No Job History found E172 the selected Job ID for the job with Job ID amp arg1 System Error PS amp R SDK Error Error retrieving Error E173 Error while retrieving E173 the job history the jobHistory from ReportNet amp arg1 System Error PS amp R Job History is not found for Error E174 No Job History found E174 the selected Request Name for the job with Request Name amp arg1 System Error PS amp R SDK Error Error retrieving Error E176 Error while retrieving E176 the job history the jobHistory from ReportNet System Error PS amp R SDK Error Cannot get the Error E179 Error while trying to E179 ReportNet Services Service get ReportNet Services Service Exception Exception amp arg1 System Error PS amp R SDK Error Cannot get the Error E180 Error while trying to E180 ReportNet Services get ReportNet Services MalformedURL Exception MalformedURL Exception amp arg1 System Error PS amp R SDK Error Cannot get the Error E181 Error while trying to E181 ReportNet Services get ReportNet Services Unhandled Exception amp arg1 User Manual February 2009 Version No 2 0 Error Messages C 24 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message ID System Error PS amp R SDK Error Error submitting Error E183 Error while trying to
93. TOTAL 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 126 Provider Statistical and Reimbursement System Report Type Data Element Description 339 TOTAL 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 TOTAL 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 TOTAL 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 TOTAL 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 TOTAL 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 TOTAL 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 TOTAL 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 TOTAL 059X All revenue code lines These fields are not populated on this report whe
94. These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 TOTAL 0274 Displays by itself These fields are not populated on this report 329 TOTAL 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 TOTAL 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 TOTAL 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 TOTAL 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 TOTAL 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 105 Provider Statistical and Reimbursement System Report Type Data Element Description 329 TOTAL 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 TOTAL 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 TOTAL 058X All reve
95. YYYY format All Only numeric characters Error E042 Paid Date s E042 entry contains a non numeric character or is not in MM DD YYYY format All Entry must be in MM DD YYYY Error E042 Paid Date s E042 format entry contains a non numeric character or is not in MM DD YYYY format All Month Day and Year values Error E001 Paid Date s E001 must be valid entry contains an invalid month day and or year All Entry must be greater than or Error E008 Paid From date E008 equal to 01 01 2006 must be on or after 01 01 2006 All Entry must be less than or Error E312 Paid Dates do E312 equal to the Paid Date To not have a valid date range Date From from date To to date Paid Date To All Field must not be null Error E042 Paid Date s E042 Date entry contains a non numeric character or is not in MM DD YYYY format User Manual February 2009 Version No 2 0 Error Messages C 14 Provider Statistical and Reimbursement System Form Field User Type Validation Error Warning Message ID All Only numeric characters Error E042 Paid Date s E042 entry contains a non numeric character or is not in MM DD YYYY format All Entry must be in MM DD YYYY Error E042 Paid Date s E042 format entry contains a non numeric character or is not in MM DD YYYY format All Month Day and Year values Error E001 Paid Date s E001 must
96. aaa a aap eek wo Claim Report Splits 720 725 Recpt Dt 010 05 TOTAL 2 95 00 95 00 0 00 0 00 0 00 0 00 95 00 Coins 0 00 Paid Dt 02 24 05 MSP 0 00 Service From 9103 05 Psyc Red Service Thru 91 31 05 Net Reim 95 00 Patm Nm JENKK Bill Freq Rev Gros Cash Blood Line Item GrossReimb 3300 MSP Cash Deduct sono DCN 2054398893360 Trans Type Code HCPCS Units Charges re Deduct Deduct COME MSP ty Reimb Less MSP Blood Deduct 000 Pum Cntrl 1uGo00000000 Processor ID 14000 0636 90658 16 00 18 00 0 00 000 0 00 0 00 1800 MSP Coins 020 Med Rerd 1000000000 3771 60008 15 00 15 00 200 000 000 sana sison Cash Deduct 0 00 Claim interest 000 HIC Num 240321813A Blood Deduct 0 00 Claim Report Splits 130 720 725 Recpt Dt 02 09 05 TOTAL 2 33 00 33 00 000 0 00 000 0 00 533 00 Coins 0 00 Paid De 02 23 05 MSP 0 00 Service From 91 17 05 Psyc Red Service Thre 911 05 Net Reimb 33 00 Monthly Totals for MOTHER MARY ESRD for service month end 1 31 05 Reimbursements Additional information Units Charges Gross Reimb Cash Deduct Blood Deduct Coins MSP Psyc Red Lineltem Reimb Gross Reimb 128 00 MSP Cash Deduct 0 00 TOTAL 4 12800 512800 0 00 0 00 0 00 0 00 128 00 Less MSP Blood Deduct 0 00 MSP Coins 000 Cash Deduct 000 Claim Imterest Amount 0 00 Blood Deduct 0 00 Coins 0 00 MSP 0 00 Psyc Red Net Reimb 128 00 _ Feb 19 2007 2 8 47 25
97. amount from the paid claim record User Manual February 2009 Version No 2 0 Report Data B 79 Provider Statistical and Reimbursement System Report Type Data Element Description 125 COINSURANCE The actual coinsurance amount from the paid claim record 125 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 125 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 125 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 135 CLAIMS Currently this field has no cost report usage 135 UNITS The number of units applicable to each revenue code 135 CHARGES The charges applicable to each revenue code 135 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 135 DESCRIPTI ON The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a com
98. and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 73A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 73A GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 73A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 73A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 73A COINSURANCE The actual coinsurance amount from the paid claim record 73A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 73A NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 73A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 74A CLAI MS Currently this field has no cost report usage 74A UNITS The number of units applicable to each revenue code 74A CHARGES The charges applicable to each revenue code 74A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Cha
99. appear in this inbox If the Status is Complete it is your responsibility during these 21 days to save the reports to your own computer Refresh Delete 85 PDF files can be viewed and printed using Adobe Reader software The files will be saved as shown in the display below Adobe Acrobat 7 0 Document 10 16 2008 1 46 PM 72 429 3 70 600 Adobe Acrobat 7 0 Document 10 16 2008 1 46 PM 72 430 3 70 595 Adobe Acrobat 7 0 Document 10 16 2008 1 46 PM 72 429 3 70 595 If Separate Files by Provider was not selected for CSV report requests when the user clicks the CSV icon the secondary page opens and when the user clicks the links the user is prompted to either save or open the ZIP file The ZIP file contains one file that contains all providers included in the request If Separate Files by Provider was not selected for PDF report requests the report will open in a new window User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 27 Provider Statistical and Reimbursement System Site Map Announcements FAQ Home Report Inbox Request Report Administration Summary Report Inbox Summary Report Inbox Request Name Separate By Provider CSY Request Name Report s File Size Separate By Provider CSV IP OP 5 KB Separate By Provider CSV 32x 33x 399 5 KB Back A report is automatically deleted from the inbox 21 days after the r
100. assigned to a report in the following sequence e A claim is presented on the SNF Inpatient Part A MSP LCC 21A report if the MSP LCC indicator is M or the claim level indicator is FR Full Recovery A claim is presented on the SNF Inpatient Part A PPS 210 report for all claims that do not match the criteria for the SNF Inpatient Part A MSP LCC 21A report 4 1 4 410 Claims Processing If a claim s Bill Type is 410 the claim is assigned to the Religious Non Medical Inpatient Part A 410 report 4 2 11x Report Template The 11x template reports are processed at the claim level There is a summary report and a detail report associated with each report within the 11x report template The Inpatient 11x Provider Summary reports display summary statistics charges reimbursements and additional information for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The data displayed in each section is determined by the report selected for generation For example if the Inpatient Long Term Care Part A PPS Interim Bills 11T report is generated the report contains inpatient long term care Part A services that have been billed on and interim basis data The statistics section displays the number of discharges the number of Medica
101. based on the outpatient 72x Hospital Based or Independent Renal Dialysis Center report template are e Hospital Based or Independent Renal Dialysis Center MSP LCC 72A e Hospital Based or Independent Renal Dialysis Center Composite Rate Services 720 e Hospital Based or Independent Renal Dialysis Center Fee Reimbursed 725 A brief description of these reports is provided in the following sections 5 2 1 Hospital Based or Independent Renal Dialysis Center MSP LCC 72A The Hospital Based or Independent Renal Dialysis Center MSP LCC 72A report is a supplemental report to the Hospital Based or Independent Renal Dialysis Center Composite Rate Services 720 report The items reported on the Hospital Based or Independent Renal Dialysis Center MSP LCC 72A report are not to be included on the Medicare Cost Report User Manual February 2009 Version No 2 0 5 9 Outpatient Reports Provider Statistical and Reimbursement System 5 2 2 Hospital Based or Independent Renal Dialysis Center Composite Rate Services 720 The Hospital Based or Independent Renal Dialysis Center Composite Rate Services 720 report summarizes data for renal dialysis centers that is bill type 72x paid based on an all inclusive rate The items reported on the Hospital Based or Independent Renal Dialysis Center Composite Rate Services 720 report are included on the Medicare Cost Report 5 2 3 Hospital Based or Independent Renal Dialysis Center
102. basis as determined by the OPPS Pricer 74P OUTLIER The outlier portion of the OPPS payment for the APC 74P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 74P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 74P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 74P COINSURANCE The actual coinsurance amount from the paid claim record 74P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 74P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 74P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 74P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 54 Provider Statistical and Reimbursement System Report Type Data Element Description 74P CLAIM INTEREST PAYMENTS Interest pay
103. by the report selected for generation The statistic section shows the number of claims for each reporting period The charge section displays the number of units and the total dollar amount of the revenue code being reported The reimbursement section displays how Net Reimbursement is calculated Finally the additional information section displays the claim interest payments The Outpatient xx0 All Other Payment Reconciliation detail report template is divided into Claim Information Reimbursements and Additional Information sections The claim information section contains patient information such as the patient name DCN Line Item Reimbursement and the charges for the revenue codes The reimbursements section shows how Net Reimbursement is calculated The additional information section shows the deductible amounts claim interest and MSP coinsurance amount The report template also provides a monthly totals section that sums the information from the sections above An example of the outpatient xx0 All Other report template and outpatient xx0 All Other Payment Reconciliation report template follow User Manual Outpatient Reports February 2009 Version No 2 0 5 34 Provider Statistical and Reimbursement System Exhibit 5 17 Outpatient xxO All Other Provider Summary Report Template PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page 1 Paid Dates 01 01 04 THRU 10 01 06 OUTPATIENT
104. by the system e Processing Modified your FI MAC Administrator has submitted the request but modified the request prior to submission for processing e Complete Modified your FI MAC Administrator modified the request prior to submission for processing and the request has completed processing e Complete your FI MAC Administrator has submitted the request and the request has completed processing e Declined your FI MAC Administrator declined the request any comments your FI MAC Administrator included with the request can be viewed by clicking the status hyperlink corresponding to the request e Error the request contains technical problems and was not completed The report requests listed in the inboxes can be sorted in ascending or descending order by clicking the column heading associated with the desired column to sort Clicking the column heading acts as a toggle to reverse the sort order with each click of the column heading An up or down arrow appears to the right of the column heading indicating the column that is currently sorted and whether the column is sorted in ascending or descending order Note Adobe Reader is required to be installed on your computer in order to view PDF files If you do not have Adobe Reader installed click the Adobe Reader hyperlink to download the software User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 24 Provider Statistical and Reimbursement System An ex
105. charges associated with revenue codes designated as ancillary 410 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as routine and ancillary User Manual February 2009 Version No 2 0 Report Data B 24 Provider Statistical and Reimbursement System Report Type Data Element Description 410 HOSPITAL SPECIFIC This line plus any federal specific amounts are the total DRG amounts other than outlier 410 FEDERAL SPECIFIC This line plus any hospital specific amounts are the total DRG amounts other than outlier 410 OUTLIER Summarizes cost outlier payments Value code 17 made under the Prospective Payment System 410 DSH LIP The DSH LIP amount value code 18 shown on the PS amp R report represents interim payments calculated by the PPS Pricer program For cost reporting purposes the DSH LIP amount must be recomputed for qualifying hospitals 410 IME TEACHING ADJ Indirect medical education Teaching adjustment Value Code 19 amount shown on the PS amp R are estimated payments made on a bill by bill basis by the PPS Pricer program For cost reporting purposes the amount must be recomputed 410 NEW TECHNOLOGY Summarizes new technology payments Value code 77 made under the Prospective Payment System 410 IPF ECT Summarizes IPF ECT Inpatient Psych Facility Electro Convulsive Therapy payments made
106. codes 810 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 810 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 810 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 810 DEDUCTIBLES The actual deductible amount from the paid claim record 810 COINSURANCE The actual coinsurance amount from the paid claim record 810 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 810 MSP RECONCILIATI ON This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 810 OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports User Manual February 2009 Version No 2 0 Report Data B 90 Provider Statistical and Reimbursement System Report Type Data Element Description 810 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include
107. contains a non numeric character or is not in MM DD YYYY format Paid Date To All Only numeric characters Error E042 Paid Date s E042 Date entry contains a non numeric character or is not in MM DD YYYY format All Entry must be in Error E042 Paid Date s E042 MM DD YYYY format entry contains a non numeric character or is not in MM DD YYYY format All Month Day and Year Error E001 Paid Date s E001 values must be valid entry contains an invalid month day and or year All Entry must be less than or Error E007 Paid To date E007 equal to the default date must be on or before CMS User the latest paid default dates date from any paid claim file FI MAC User the latest paid date from a paid claim file loaded for that FI MAC Parent Provider and Freestanding Child Provider User the latest paid date from a paid claim file loaded for the provider s FI MAC All Entry must be greater than Error E312 Paid Dates do E312 or equal to the Paid Date From Date not have a valid date range From from dates To to dates User Manual February 2009 Version No 2 0 Error Messages C 8 Provider Statistical and Reimbursement System Form Field Parent Provider no longer has access to a provider User Type Parent Provider Validation If you are requesting a report from when a parent provider owned a child provider it must be in the
108. display as All other Part B revenue code charges they come in on the claim they do not roll up 399 SCIC PEP 0023 Does not display These fields are not populated on this report 399 SCIC PEP 027X All revenue code lines Part B medical supplies charges where the first three positions 027 excluding 0274 are rolled up 399 SCIC PEP 0274 Displays by itself Part B prosthetics and orthotics charges 399 SCIC PEP 029X All revenue codes Part B durable medical equipment charges lines where the first three positions 029 are rolled up 399 SCIC PEP 042X All revenue code lines Total physical therapy covered charges during SCIC PEP where the first three positions 042 episode are rolled up 399 SCIC PEP 043X All revenue code lines Total occupational therapy covered charges during SCI C PEP where the first three positions 043 episode are rolled up 399 SCIC PEP 044X All revenue code lines Total speech therapy covered charges during SCIC PEP where the first three positions 044 episode are rolled up 399 SCIC PEP 055X All revenue code lines Total covered charges related to nursing services during where the first three positions 055 SCIC PEP episode are rolled up 399 SCIC PEP 056X All revenue code lines Total covered charges related to med soc serv during SCIC where the first three positions 056 are rolled up PEP episode User Manual February 2009 Version No 2 0 Re
109. e A claim is presented on the Inpatient Psych Part A PPS 11V report the if Provider ID is xx4000 through xx4499 or xxSxxx or xxMxxxx and FSP does not equal zero 0 and Patient Status Code is 30 and benefits are not exhausted Occurrence Code is not A3 B3 C3 E3 F3 or G3 User Manual Inpatient Reports February 2009 Version No 2 0 4 3 Provider Statistical and Reimbursement System e A claim is presented on the Inpatient Psych PPS Interim Bills 11U report if the Provider ID is xx4000 through xx4499 or xxSxxx or xxMxxxx and FSP does not equal zero 0 A claim is presented on the Inpatient PPS Interim Bills 119 report if the Patient Status Code is 30 the Diagnostic Related Group DRG Code is greater than zero 0 and the Federal Specific Portion is not zero 0 e A claim is presented on the Inpatient Part A 110 report for all remaining claims and claim lines 4 1 2 18x Claims Processing If a claim s Bill Type is 18x the claim is assigned to a report in the following sequence e A claim is presented on the Swing Bed SNF MSP LCC 18A report if the MSP LCC indicator is M or the claim level indicator is FR Full Recovery A claim is presented on the Swing Bed SNF 180 report for all claims that do not match the criteria for the Swing Bed SNF MSP LCC 18A report 4 1 3 21x Claims Processing If a claim s Bill Type is 21x the claim is
110. etc 11K CALCULATED NET REIMB FOR PIP CLAIMS For intermediary use Indicates that provider received PIP payments May be used to identify duplicate payments 11K ACTUAL CLAIM PAYMENTS FOR PIP Sum of interest paid on claims due to untimely claims processing Currently this field has no cost report usage 11K CLAIM INTEREST PAYMENTS The 25 penalty assessed for failure to submit IRF PAI data timely 11K IRF PENALTY AMOUNT The per diem payments made under PPS to the provider for a patient s stay in the facility prior to being transferred to another facility These payments are included in the net reimbursement field This field is shown for informational purposes only User Manual February 2009 Version No 2 0 Report Data B 13 Provider Statistical and Reimbursement System Report Type Data Element Description 11K LTCH SHORT STAY OUTLIER PAYMENTS This field reflects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 11A 18A 21A 118 and all other inpatient reports are transferred to the cost report 11K CAP FED SPECIFIC 10096 This field equals the federa
111. field cannot exceed 1 0000 For non transfer cases the amount 1 0000 will always appear in this field User Manual February 2009 Version No 2 0 Report Data B 17 Provider Statistical and Reimbursement System Report Type Data Element Description 11R DRG WEIGHT FRACTION This is the actual weight of the DRG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS operating payments made to a specific provider 11R DRG WEIGHT FRACTION This field reflects the DRG weight times the discharge fraction DISCHARGES divided by the discharges This amount can be used to calculate a transfer adjusted case mix 11S DISCHARGES This field is only valid for inpatient claims This indicates the number of patients discharged 11S MEDICARE DAYS The provider s hospital routine adults and peds days Note The provider s crosswalk may be used to allocate days for cost reporting purposes 11S CLAI MS Currently this field has no cost report usage 11S UNITS The number of units applicable to each revenue code Note for accommodations revenue codes this may include non covered days 11S CHARGES The charges applicable to each revenue code 11S REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of
112. first three positions 062 are rolled up These fields are not populated on this report 339 PEP 0623 Displays by itself These fields are not populated on this report 339 PEP All other Rev Codes display as they come in on the claim they do not roll up These fields are not populated on this report 339 SCIC PEP 0023 Does not display These fields are not populated on this report 339 SCIC PEP 027X All revenue code lines where the first three positions 027 excluding 0274 are rolled up These fields are not populated on this report 339 SCIC PEP 0274 Displays by itself These fields are not populated on this report 339 SCIC PEP 029X All revenue codes lines where the first three positions 029 are rolled up These fields are not populated on this report User Manual February 2009 Version No 2 0 Report Data B 130 Provider Statistical and Reimbursement System Report Type Data Element Description 339 SCIC PEP 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 SCIC PEP 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 SCIC PEP 044X All revenue code lines
113. from the paid claim records 11U BLOOD DEDUCTIBLE The sum of actual blood deductible amount from the paid claim records 11U COINSURANCE The sum of actual coinsurance amount from the paid claim records 11U NET MSP PAYMENTS The sum of net payments made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 11U MSP PASS THRU RECONCILIATI ON This field is informational only and should not be included in the cost report This amount occurs in cases where Medicare has made no payment on the claim yet classifies it as PR Partial Recovery because of the estimated pass through payments The actual pass through amounts will be determined in the cost report The MSP Pass Thru Reconciliation amount must be ignored for cost reporting 11U OTHER ADJ USTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 11U NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 11U CALCULATED NET REIMB FOR PIP CLAIMS For intermediary use Indicates that provider received PIP payments May be used to identify duplicate payments 11U ACTUAL CLAIM PAYMENTS FOR PIP This field re
114. information reimbursements and additional information sections The claim information section contains patient information such as the patient name DCN Line Item Reimbursement and the charges for the revenue codes The reimbursements section shows how Net Reimbursement is calculated The additional information section shows the deductible amounts claim interest and MSP Coinsurance The report template also displays a monthly totals section that sums the information from the sections above User Manual Outpatient Reports February 2009 Version No 2 0 5 25 Provider Statistical and Reimbursement System An example of the xx2 Outpatient Vaccines Provider Summary report template and xx2 Outpatient Vaccines Payment Reconciliation detail report template follow Exhibit 5 12 Outpatient xx2 Vaccines Provider Summary Report Template PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page 1 Paid Dates 01 01 04 THRU 10 01 05 OUTPATIENT PART 8 VACCINE Report 0042203 Report Run Date 02 05 07 Report Type 132 Provider FYE 12 21 Provider Number 192305 MOTHER MARY ESRD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 04 12 31 04 01 01 05 12 31 05 No Data Requested No Data Requested STATISTIC SECTION CLAIMS 1 2 CHARGE SECTION REV CODE DESCRIPTION UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES 0636 DRUGS DETAIL CODE 1 18 00 2 38 00 077
115. lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the SNF Outpatient OPPS 22P report are included on the Medicare Cost Report 5 4 5 SNF Outpatient OPPS 23P The SNF Outpatient OPPS 23P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the SNF Outpatient OPPS 23P report are included on the Medicare Cost Report 5 4 6 SNF Outpatient OPPS 24P The SNF Outpatient OPPS 24P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the SNF Outpatient OPPS 24P report are included on the Medicare Cost Report 5 4 7 Home Health Outpatient OPPS not HHPPS 34P The Home Health Outpatient OPPS not HHPPS 34P report summarizes the Part B claims data not under a signed plan of care that are reimbursed under Outpatient Prospective Payment System This report is used in cost reports prior to October 1 2000 The items reported on the Home Health Outpatient OPPS not HHPPS 34P report are included on the Medicare Cost
116. mail jane doe purplepanda com Fax 703 555 3291 Reason for Request year end reporting Service Periods Provider Period 1 eriod 2 Period 3 D 01301 From 01 01 2006 From 04 01 2006 From 07 01 2006 From 10 01 2006 Lr j To 03 31 2006 To 06 30 2006 To 09 30 2006 To 12 31 2006 xi Note This request will generate up to 4 Detail Report s Data does not exist for the Provider Report combinations listed as No Data Available for the chosen Service Paid Date Periods therefore no report s will be generated for these providers reports I Save Request as Favorite Favorite Name 50 Char JF v TRTESTT7 D 9801 ES User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 22 Provider Statistical and Reimbursement System 10 Type the request name or accept the default name The request name can be up to 50 characters Select the Exclude check box to exclude any providers from the report s To save the request to your Favorite Requests list select the Save Request as Favorite check box Type the request name or accept the default name Up to 100 favorite report requests can be saved To access a saved report select the Favorite Requests option from the Request Report menu Refer to Section 3 5 Favorite Requests for additional information 11 Click Submit to submit the report request or click Back to return to the previous page Once Submit is selected the r
117. not in MM DD YYYY format All Entry must be in MM DD YYYY Error E038 Service Date s E038 format entry for Provider ID contains a non numeric character or is not in MM DD YYYY format All Month Day and Year values Error E001 Service Date E001 must be valid entry for Provider ID contains an invalid month day and or year All Entry must be less than or Error E312 Period E312 equal to corresponding service dates do not have a Service Period To Date valid date range for Provider ID From from date To to date All Entry must be greater than Error E092 Service Periods E092 the previous Service Period To overlap and or are not Date this assures chronological for Provider chronological service periods ID and that there is no overlapping service periods All user Entry is one day greater than Warning W001 You have W001 types except previous Service Period To selected non consecutive for Date this checks to see if the service periods for Freestanding service periods are provider s amp arg1 Do you Providers consecutive wish to continue Freestanding Entry is one day greater than Warning W003 You have W003 Providers previous Service Period To selected non consecutive only Date this checks to see if the service periods Do you wish service periods are to continue consecutive Update Service All Field must not be null Error E038 Service Date s E0
118. on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 22Z CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 23Z CLAI MS Currently this field has no cost report usage 23Z UNITS The number of units applicable to each revenue code 23Z CHARGES The charges applicable to each revenue code 23Z GROSS FEE AMT This is an accumulation of 10096 fee reimbursed ambulance services Sorted by trips and mileage 23Z TOTAL AMBULANCE TRI PS Accumulated number of trips from paid claims 23Z TOTAL AMBULANCE MILES Accumulated number of miles from paid claims 23Z TOTAL GROSS FEE SCHEDULE AMT This is an accumulation of 10096 fee reimbursed ambulance services 23Z REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes User Manual February 2009 Version No 2 0 Report Data B 62 Provider Statistical and Reimbursement System Report Type Data Element Description 23Z DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all re
119. paid claim record 34P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 34P COINSURANCE The actual coinsurance amount from the paid claim record 34P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 34P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 34P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 34P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 51 Provider Statistical and Reimbursement System Report Type Data Element Description 34P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 34P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive
120. payments The Outpatient xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Payment Reconciliation detail report template is divided into Claim Information Reimbursements and Additional Information sections The claim information section contains patient information such as the patient name DCN HCPCS total and the charges for the revenue codes The reimbursements section shows how Net Reimbursement is calculated The additional information section shows the deductible amounts and the claim interest The report template provides a monthly totals section that sums the information from the sections above An example of the Outpatient xx A Medicare Secondary Payer Lower Cost or Charge MSP LCC Provider Summary report template and Outpatient xx A Medicare Secondary Payer Lower Cost or Charge MSP LCC Payment Reconciliation detail report template follow User Manual Outpatient Reports February 2009 Version No 2 0 5 10 Provider Statistical and Reimbursement System Exhibit 5 3 Outpatient xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Provider Summary Report Template Program ID REDESIGN Paid Dates 02 01 04 THRU 10 01 06 Report Run Date 02 01 07 Provider FYE 12 31 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PROVIDER SUMMARY REPORT Page OUTPATIENT ALL OTHER MSP LCC Report 0042203 THESE ITEMS ARE NOT TO BE INCLUDED ON THE MEDICARE COST REPORT Report Type 134 Provider Number T
121. payments such as bi weekly pass through payments lump sums and financial adjustments etc 12Z CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 13Z CLAI MS Currently this field has no cost report usage User Manual February 2009 Version No 2 0 Report Data B 60 Provider Statistical and Reimbursement System Report Type Data Element Description 13Z UNITS The number of units applicable to each revenue code 13Z CHARGES The charges applicable to each revenue code 13Z GROSS FEE AMT This is an accumulation of 10096 fee reimbursed ambulance services Sorted by trips and mileage 13Z TOTAL AMBULANCE TRI PS Accumulated number of trips from paid claims 13Z TOTAL AMBULANCE MILES Accumulated number of miles from paid claims 13Z TOTAL GROSS FEE SCHEDULE AMT This is an accumulation of 10096 fee reimbursed ambulance services 13Z REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 13Z DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 13Z TOTAL COVERED
122. penalty assessed for failure to submit IRF PAI data timely 11R LTCH SHORT STAY OUTLIER PAYMENTS The per diem payments made under PPS to the provider for a patient s stay in the facility prior to being transferred to another facility These payments are included in the net reimbursement field This field is shown for informational purposes only 11R CAP FED SPECIFIC 10096 Note This field equals the federal specific field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period This field should be used by hold harmless providers only 11R CAP OUTLIER 10096 Note This field equals the outlier field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period 11R DRG CMG WEIGHT This is the actual weight of the DRG CMG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS operating payments made to a specific provider 11R WEIGHT DISCHARGES This is the actual weight non transfer adjusted of the DRG determined by the PPS Pricer program divided by the discharges 11R DISCHARGE FRACTION For transfer cases the billed days are divided by the average length of stay for the DRG and the result is entered in this field The amounts in this
123. populated on this report where the first three positions 043 are rolled up 339 SCIC 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 SCIC 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 SCIC 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 SCIC 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 SCIC 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 SCIC 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 SCIC 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 SCIC 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 SCIC 0623 Displays by itself These fields are not populated on this report 339 SCIC All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 339 TOTAL 0023 Does no
124. populated on this report where the first three positions 060 are rolled up 329 PEP 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 PEP 0623 Displays by itself These fields are not populated on this report 329 PEP All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 SCIC PEP 0023 Does not display These fields are not populated on this report 329 SCIC PEP 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 SCIC PEP 0274 Displays by itself These fields are not populated on this report 329 SCIC PEP 029X All revenue codes These fields are not populated on this report lines where the first three positions 029 are rolled up 329 SCIC PEP 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 SCIC PEP 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 SCIC PEP 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 SCIC PEP 055X All revenue code lines These fields are not populated on this report where
125. preferences User Manual System Overview and Common Features February 2009 Version No 1 2 8 Provider Statistical and Reimbursement System Exhibit 2 8 Home Page Site Map Announcements FAQ Help care and Medicaid Service CNS Provider Statistical amp Reimbursement System August 15 Home Report Inbox Request Report Administration User Preferences PS amp R Home Welcome to The Redesigned Provider Statistical and Reimbursement System 2 3 Field and Control Overview There are several standard forms with which users interact throughout the PS amp R System to select report parameters and to maintain administrative data for authorized users The subsequent sections provide a description of the following control types and system conventions utilized in the PS amp R System e Radio buttons e Check boxes e Drop down menus e List box e Transfer list box e Calendar e Command buttons User Manual System Overview and Common Features February 2009 Version No 1 2 9 Provider Statistical and Reimbursement System e Keyboard shortcuts e Special characters 2 3 1 Radio Buttons Radio buttons allow a user to select one of a limited number of mutually exclusive options The following exhibit provides an example of radio buttons used in the PS amp R System Exhibit 2 9 Radio Buttons PDF C CSV C PDF amp CSV The example in the exhibit above contains three radio button options
126. report where the first three positions 056 are rolled up 329 PEP 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 PEP 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 PEP 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 PEP 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 PEP 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 PEP 0623 Displays by itself These fields are not populated on this report 329 PEP All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 SCIC PEP 0023 Does not display These fields are not populated on this report 329 SCIC PEP 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 SCIC PEP 0274 Displays by itself These fields are not populated on this report 329 SCIC PEP 029X All revenue codes These fields are not populated on this report lines where the first three positions 029 are rol
127. report where the first three positions 057 are rolled up 339 TOTAL 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 TOTAL 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 TOTAL 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 TOTAL 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 TOTAL 0623 Displays by itself These fields are not populated on this report 339 TOTAL All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 339 SERVICES WITH OUTLIER These fields are not populated on this report 339 FULL 0023 Does not display These fields are not populated on this report 339 FULL 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 FULL 0274 Displays by itself These fields are not populated on this report 339 FULL 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data
128. revenue code lines Total visit covered charges for various disciplines for SCIC where the first three positions 059 only episode are rolled up 399 SCIC 060X All revenue code lines Part B Oxygen charges where the first three positions 060 are rolled up 399 SCIC 062X All revenue code lines Part B Med Supplies charges where the first three positions 062 are rolled up 399 SCIC 0623 Displays by itself Part B Surgical Dressings charges 399 SCIC All other Rev Codes display as All other Part B Revenue Code Charges they come in on the claim they do not roll up 399 TOTAL 0023 Does not display These fields are not populated on this report 399 TOTAL 027X All revenue code lines Total Part B medical supplies charges where the first three positions 027 excluding 0274 are rolled up 399 TOTAL 0274 Displays by itself Total Part B prosthetic and orthotic device charges 399 TOTAL 029X All revenue codes lines Total Part B durable medical equipment charges where the first three positions 029 are rolled up 399 TOTAL 042X All revenue code lines Total Part B physical therapy count where the first three positions 042 are rolled up 399 TOTAL 043X All revenue code lines Total Part B occupational therapy count where the first three positions 043 are rolled up 399 TOTAL 044X All revenue code lines Total Part B speech count where the first three positions 044 are rolled up 399 TOTAL 055X All r
129. revenue codes 11S DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 11S TOTAL ACCOMODATI ONS This category may include provider liable days that are non covered days This category may be used to prorate the Medicare Days field for cost reporting purposes 11S TOTAL ANCILLARY All Medicare covered charges associated with revenue codes designated as ancillary 11S TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as routine and ancillary 11S HOSPITAL SPECIFIC This line plus any federal specific amounts are the total DRG amounts other than outlier 11S FEDERAL SPECIFIC This line plus any hospital specific amounts are the total DRG amounts other than outlier 11S OUTLIER Summarizes cost outlier payments Value code 17 made under the Prospective Payment System 11S DSH LIP The DSH LIP amount value code 18 shown on the PS amp R report represents interim payments calculated by the PPS Pricer program For cost reporting purposes the DSH LIP amount must be recomputed for qualifying hospitals User Manual February 2009 Version No 2 0 Report Data B 18 Provider Statistical and Reimbursement System Report Type Data Element Description 11S IME TEACHING ADJ Indirect medical education Teaching adjustm
130. s 525 9 36 00 000 0 55 93 mn Tot Gross Fee Sched sna HIC Num 1935722204 ESRD Condition Code Deductibies 0 00 Recpt Dt 05 03 08 Cole 877 09 Paid c 0517 04 Units Charges wan Deducibles Com MSP pen e pen Pete pag sr 0 00 Service From ON ING Other Adis 9 00 Service Tors UU Subtotal Report 13Z 7 674700 5238835 000 87709 000 000 3000 S151126 mep recon 000 TOTAL 7 944700 2 38835 0 00 077 09 000 000 0 00 151126 ese Rens baa New Pyra Pyyc Red Net Reimb 3151126 Patnt Nre COXS BM Frege aw Gross MSP tSADR cn Pye Uneltem PEER Gross Reimb 315242 MSP Deductibles 0 00 DON 20488380753505 Trans Type Code OS Units Charges Reimb Deductibles Coin MS Recor Meaka Red Ruin arc Report Outer 500 MSP Coins 0 00 Pint Cntri 9 041000000000 Processor ID naco 540 ADS 000 snas E 25 92 Less Calm interest 0 00 Med Rerd 8 591000000000 Zip Code 32822 0540 aoas 1 325 00 155 76 000 350 33 000 0 00 30 00 10537 0 1x Tot Gross Fee Sched 2542 MIC Num 1530057544 ESRD Condition Code Deductibles 30 00 Recpt Dt 04 30 04 Com 5153 Paid De 05 1454 Uns Cue ung Deducibles Com MSP pon Mee pee Puce ngng MSP 3000 Service From 02 25 04 Other Adis 9 00 reese saline Subtotal Report 137 10 388 00 192 82 000 6153 000 000 0 00 191 29 apren sato TOTAL 10 3800 1922 000 5153 000 000 000 13123 teRDR cn 2 New Pymts Paye Red
131. the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS operating payments made to a specific provider 11S WEIGHT DISCHARGES This is the actual weight non transfer adjusted of the DRG determined by the PPS Pricer program divided by the discharges 11S DISCHARGE FRACTION This field does not apply and will be zero 11S DRG WEIGHT FRACTION This field does not apply and will be zero 11S DRG WEIGHT FRACTION This field does not apply and will be zero DISCHARGES 11T DISCHARGES This field is only valid for inpatient claims This indicates the number of patients discharged 11T MEDICARE DAYS The provider s hospital routine adults and peds days Note The provider s crosswalk may be used to allocate days for cost reporting purposes 11T CLAI MS Currently this field has no cost report usage 11T UNITS The number of units applicable to each revenue code Note for accommodations revenue codes this may include non covered days 11T CHARGES The charges applicable to each revenue code 11T REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 11T DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes
132. the parameters of the favorite request Favorite report requests can be saved for summary reports and detail reports The Favorite Requests page appears as follows Map Announcements FAQ Help Logout CNS Provider Statistical amp Reimbursement System SLOBAL FI MAC 14000 User ID TRTE Favorite Requests Thursday August 23 Home Report Inbox juest Favorite Requests Request Summary Request Detail Favorite Requests 4 of 100 in use Remove Contractor Favorite Favorite Name 1D Saved Date V Category Recently Run a Request Name Request Date FAV TRTEST17 D T r PARROTHEAD 14000 08 23 2007 Detail TRTEST17 D 9904 08 23 2007 EAV TRTEST17 S TRETESTI7 S CO 100007 QUARTERLY 14000 08 23 2007 Summary T00007 08 23 2007 r EAV TRTEST17 DETAIL 14000 08 23 2007 Detail TRTEST17 D 9901 08 23 2007 r EAM TRTEST17 SUMMAR Y 14000 08 23 2007 Summary TRTEST17 S 9900 08 23 2007 You are allowed to save up to 100 reports as favorites It is your responsibility to manage your favorites list and ensure that you do not exceed the limit Refresh Remove The Favorite Requests page displays the favorite name contractor ID the date the favorite request was saved the type of favorite request the request name for the most recently generated report based on the favorite request and the last date the favorite request was used to generate a report Up to 100 favorite requests can be saved at any given time To delete a fav
133. the Home Health Part A MSP LCC 33M report are included on the Medicare Cost Report 5 9 4 Home Health PPS Part A Episodes 339 The Home Health PPS Part A Episodes 339 report summarizes data included on Part A home health prospective payment episodes Part A home health data is separated into different episode units The items reported on the Home Health PPS Part A Episodes 339 report are included on the Medicare Cost Report 5 9 5 Home Health PPS Part A and Part B Episodes 399 The Home Health PPS Part A and Part B Episodes 399 report summarizes home health episode data from the Home Health PPS Part B Episodes 329 report and the Home Health PPS Part A Episodes 339 report The items reported on the Home Health PPS Part A and Part B Episodes 399 report are included on the Medicare Cost Report 5 10 322 332 Home Health Agency Report Template The 322 332 Home Health Agency Provider Summary report template displays a RAP and a reimbursement section for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The RAP section shows the total initial RAPs total cancelled RAPs and the total RAPs outstanding for the different service periods The reimbursement section shows gross reimbursement and net reimbursement The 322 332 Home Healt
134. the estimated pass through payments The actual pass through amounts will be determined in the cost report The MSP Pass Thru Reconciliation amount must be ignored for cost reporting 118 OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 118 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 118 CALCULATED NET REIMB FOR PIP CLAIMS For intermediary use Indicates that provider received PIP payments May be used to identify duplicate payments User Manual February 2009 Version No 2 0 Report Data B 6 Provider Statistical and Reimbursement System Report Type Data Element Description 118 ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 11A 18A 21A 118 and all other inpatient reports are transferred to the cost report 118 CLAIM INTEREST PAYMENTS Sum of interest paid on claims due to untimely cl
135. the first three positions 043 episode are rolled up 399 SCIC PEP 044X All revenue code lines Total speech therapy covered charges during SCIC PEP where the first three positions 044 episode are rolled up 399 SCIC PEP 055X All revenue code lines Total covered charges related to nursing services during where the first three positions 055 SCIC PEP episode are rolled up 399 SCIC PEP 056X All revenue code lines Total covered charges related to med soc serv during SCIC where the first three positions 056 are rolled up PEP episode User Manual February 2009 Version No 2 0 Report Data B 150 Provider Statistical and Reimbursement System Report Type Data Element Description 399 SCIC PEP 057X All revenue code lines Total covered charges related to home health aide serv during where the first three positions 057 SCIC PEP episode are rolled up 399 SCIC PEP 058X All revenue code lines Part B other visits where the first three positions 058 are rolled up 399 SCIC PEP 059X All revenue code lines Total visit covered charges for various disciplines for SCIC PEP where the first three positions 059 episode are rolled up 399 SCIC PEP 060X All revenue code lines Part B oxygen charges with outlier where the first three positions 060 are rolled up 399 SCIC PEP 062X All revenue code line
136. the name corresponding to the provider number and report type combination to navigate the contents of the desired report User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 29 Provider Statistical and Reimbursement System An example of the summary report cover page follows PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM REPORT COVER PAGE FOR REQUEST TRTEST16 S T00007 ALL Provider Report Type Total amp of Pages Prowder Report Type Total of Pages Prowder Report Type Total of Pages Provider Report Type Total of Pages T00007 110 5 T00007 115 1 T00007 118 1 T00007 11A 1 TO00007 122 1 T00007 125 1 T00007 12P 1 T00007 130 1 TO00007 135 1 T00007 13A 1 T00007 13P 2 T00007 13Z 1 T00007 140 1 700007 145 1 TOD007 14P 1 An example of a summary report in PDF format follows PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page Paid Dates 01 01 05 THRU 10 01 06 SNF INPATIENT PART A PPS Report amp OD44203 Report Run Date 02 05 07 Report Type 210 Provider FYE 05 30 Provider Number T95425 QUAKER HOME SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 05 03 31 05 04 01 05 06 30 05 07 01 05 09 30 05 10 01 05 12 31 05 STATISTIC SECTION DISCHARGES 0 o 25 0 MEDICARE DAYS 0 o 607 0 CLAIMS 0 0 4T 0 CHARGE SECTION ACCOMMODATION CHARGES REV CODE DESCRIPTION UNITS CHARGES UNITS C
137. the paid claim record 34A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 34A NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 34A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 71A CLAI MS Currently this field has no cost report usage 71A UNITS The number of units applicable to each revenue code 71A CHARGES The charges applicable to each revenue code 71A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 71A DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 71A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 71A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 71A CASH DEDUCTIBLE The actual cash deductible amount from the paid c
138. these reports is provided in the following sections 5 4 1 Inpatient Part B OPPS 12P The Inpatient Part B OPPS 12P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the Inpatient Part B OPPS 12P report are included on the Medicare Cost Report 5 4 2 Outpatient OPPS 13P The Outpatient OPPS 13P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the Outpatient OPPS 13P report are included on the Medicare Cost Report 5 4 3 Outpatient Other OPPS 14P The Outpatient Other OPPS 14P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the Outpatient Other OPPS 14P report are included on the Medicare Cost Report 5 4 4 SNF Outpatient OPPS 22P The SNF Outpatient OPPS 22P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including
139. this report where the first three positions 043 are rolled up 339 FULL 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 FULL 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 FULL 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 FULL 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 FULL 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 FULL 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 FULL 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 FULL 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 FULL 0623 Displays by itself These fields are not populated on this report 339 FULL All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 339 LUPA 0023 Does not display These fields are n
140. three positions 062 are rolled up 339 SCIC PEP 0623 Displays by itself These fields are not populated on this report 339 SCIC PEP All other Rev Codes display These fields are not populated on this report as they come in on the claim they do not roll up 339 SCIC 0023 Does not display These fields are not populated on this report 339 SCIC 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 SCIC 0274 Displays by itself These fields are not populated on this report 339 SCIC 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 125 Provider Statistical and Reimbursement System Report Type Data Element Description 339 SCIC 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 SCIC 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 SCIC 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 SCIC 055X All revenue code lines These fields are not populated on this re
141. to dates for each of the four reporting periods If interval and start dates are not applied the report is generated using the default dates populated when you accessed the page Update Service Dates by Interval Optional Type the start date in MM DD YYYY format for each of the four reporting periods to assign the reporting period range individually or click the calendar icon to select the start date using the calendar Scroll through the months and select the date to use Click Apply to apply the dates to all providers for the from and to dates for each of the four reporting periods Optional Type the end date in MM DD YYYY format for each of the four reporting periods to assign the reporting period range individually or click the calendar icon to select the end date using the calendar Scroll through the months and select the date to use Click Apply to apply the dates to all providers for the from and to dates for each of the four reporting periods Update Service Dates by Interval Optional Type the start date in MM DD YYYY format for each of the four reporting periods to assign the reporting period range individually for a provider Optional Type the end date in MM DD YYYY format for each of the four reporting periods to assign the reporting period range individually for a provider The default value is the latest paid cycle date from the paid claim files loaded for the FI MAC Type the start date in MM DD YYYY format for the c
142. usage 725 UNITS The number of units applicable to each revenue code 725 COV CHG PYMTS The charges applicable to each revenue code 725 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes User Manual February 2009 Version No 2 0 Report Data B 88 Provider Statistical and Reimbursement System Report Type Data Element Description 725 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 725 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 725 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 725 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 725 COINSURANCE The actual coinsurance amount from the paid claim record 725 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 725 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass throu
143. were chosen Provider C 8 Detail Report Request Select Report s The Detail Report Request Select Report s page error messages are presented in the following table Exhibit C 8 Detail Report Request Select Report s Page Error Messages Form Field User Type Validation Error Message ID By Service Type All If By Report Type radio Error E034 No reports were E034 Radio Button button or By Report Number selected radio button is not clicked this radio button must be clicked By Service Type All If the provider is only given Error E326 The 998 Report E326 Inpatient access to Inpatient the 998 is only applicable to outpatient Providers only report cannot be selected Providers By Report Group All If radio button is clicked at Error E036 By Report Type E036 Radio Button least one report group must option selected but no report be selected group s chosen If By Service Type radio Error E034 No reports were E034 button or By Report Type selected radio button is not clicked this radio button must be clicked By Report Group All If the provider is only given Error E326 The 998 Report E326 Inpatient access to Inpatient the 998 is only applicable to outpatient Providers only report cannot be selected Providers By Report Type All If radio button is clicked at Error E037 By Report Type E037 Radio Button least one report t
144. with outlier where the first three positions 029 are rolled up 399 TOTAL 042X All revenue code lines Total Part A and Part B occupational therapy visit count for all where the first three positions 042 disciplines are rolled up 399 TOTAL 043X All revenue code lines Total Part A and Part B occupational therapy visit count for all where the first three positions 043 disciplines are rolled up 399 TOTAL 044X All revenue code lines Total Part A and Part B speech therapy visit count for all where the first three positions 044 disciplines are rolled up 399 TOTAL 055X All revenue code lines Total Part A and Part B visit count related to nursing services where the first three positions 055 for all disciplines are rolled up 399 TOTAL 056X All revenue code lines Total Part A and Part B visit count related to med soc serv for where the first three positions 056 are rolled up all disciplines User Manual February 2009 Version No 2 0 Report Data B 146 Provider Statistical and Reimbursement System Report Type Data Element Description 399 TOTAL 057X All revenue code lines Total Part A and Part B visit count related to home health aide where the first three positions 057 serv for all disciplines are rolled up 399 TOTAL 058X All revenue code lines Part B other visits with outlier where the first three positions
145. 0 00 67 8 394 43 0 0 0 0 00 3 1 623 75 776 420 010 00 0 0 0 0 00 0 0 00 1 160 49 256 14 820 60 0 0 0 0 00 0 107 14 58 11 5770464 14 138 757 1 991 454 55 0 0 0 0 00 151 15 1 992233 14 7 222 61 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 151 15 1 992 233 14 7 222 61 0 00 0 00 0 00 0 00 0 00 eis 8 20 34 PM PROVIDER SUMMARY REPORT HOSPICE NON HOSPITAL BASED SERVICES FOR PERIOD 04 01 04 06 30 04 581 SERVICES FOR PERIOD 07 01 04 09 30 04 Page 1 Report 0044203 Report Type 810 SERVICES FOR PERIOD 10 01 04 12 31 04 o o 5 o 561 o UNDUP HOURS UNITS CHARGES User Manual February 2009 Version No 2 0 Outpatient Reports 5 48 Provider Statistical and Reimbursement System Exhibit 5 27 Outpatient 81x 82x Hospice Payment Reconciliation Detail Report Template PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page Service Month End 03 31 04 HOSPICE NON HOSPITAL BASED Report OD44202 Report Run Date 02 07 07 Report Type 810 Provider FYE 12 31 Paid Dates 01 01 04 to 10 01 06 Provider Number T01515 BIRD SONG HOSPICE Patnt Nex BRO Bl Free a Gross Foe Gross Gross Remb 3872 83 Claim interest 0 00 DCN 20419418481705 01 Trans Type c Hours Units Charges HCPCS Romb Roimb um Patient CBSA 3600 Ptt Cool 8 100020000000
146. 0 SHATTERED HEART ESRD 702581 INDIAN BEACH DIALYSIS CENTER zl II Expand I Include Subunits Continue 2 Select the provider s for which to generate a report The following table contains a description of each field on the page Field Definition Providers Required Select the providers to include in the report request If a provider is listed in red text the FI MAC no longer services the provider but can generate reports for the time period of its ownership Once a provider number is highlighted click the 55 button to select the provider number Once a provider number is selected highlight the provider number from the list of selected provider numbers and click the button to remove the provider number To locate a provider number in the list of providers type the desired provider number in the Search text box to scroll to the provider number based on the entered criteria User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 15 Provider Statistical and Reimbursement System Field Definition Optional Select the check box to increase the width of the list box Expand containing providers allowing the complete provider name to display in the list box Optional Select the check box to indicate that subunits associated with provider s that is all providers owned by a parent provider are to be included in the report Include Subunits 3 Once the provider
147. 0 digits valid secondary Fax Please reenter a valid 10 digit fax number to proceed E130 Secondary E mail Provider If data is provided entry Error E130 Please enter field must contain the a valid secondary e mail symbol address User Manual February 2009 Version No 2 0 Error Messages C 40 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message E150 FI MAC Provider FI MAC Admin Comments must be entered Error E150 Requests Decline in the comment field before Decline Modify Comments button Decline button can be are required clicked E150 FI MAC Provider FI MAC Admin If the modify button is Error E150 Requests Modify clicked and a part of the Decline Modify Comments button report is changed are required Comments must be entered in the comment field before submission E152 Your Request Name All This field must not contain Error E152 Request special characters V Name can not contain lt gt special characters V E152 Your Request Name All This field can only contain Request Name can only Field alpha numeric characters contain alpha numeric and the following special characters and the characters _ following special characters _ E152 FI MAC Provider All This field must not contain Error E152 Request Requests Your special charac
148. 00 000 FEDERAL SPECIFIC 0 00 814 69 0 00 000 OUTLIER 0 00 0 00 0 00 0 00 HOLD HARMLESS 0 00 0 00 0 00 0 00 DSH 0 00 5102 97 0 00 0 00 INDIRECT MEDICAL EDUCATION 0 00 5182 71 0 00 0 00 EXCEPTIONS 0 00 0 00 0 00 0 00 TOTAL CAPITAL PAYMENTS 0 00 1 101 37 0 00 0 00 PAYMENT GROSS REIMBURSEMENT 0 00 15 508 83 0 00 0 00 LESS DEVICE CREDIT 0 00 0 00 0 00 0 00 CASH DEDUCTIBLE 0 00 1 904 00 0 00 0 00 BLOOD DEDUCTIBLE 0 00 0 00 0 00 0 00 COINSURANCE 0 00 0 00 0 00 0 00 NET MSP PAYMENTS 0 00 2 102 00 0 00 0 00 MSP PASS THRU RECONCILIATION 0 00 0 00 0 00 0 00 OTHER ADJUSTMENTS 0 00 6 247 63 0 00 0 00 Sep 22 2008 2 1 29 49 PM User Manual February 2009 Version No 2 0 Inpatient Reports 4 7 Exhibit 4 6 Provider Statistical and Reimbursement System Inpatient 11x Provider Summary Report Template Page 3 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page 3 Paid Dates 07 01 04 THRU 11 20 06 INPATIENT PART A MSP LCC Report amp OD44203 Report Run Date 03 22 08 Report Type 11A Provider FYE 06 30 Provider Number 100001 SHANDS JACKSONVILLE MEDICAL CENTER SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 10 01 04 09 30 05 10 01 05 09 30 06 10 01 06 03 30 07 10 01 07 09 30 08 NET REIMBURSEMENT 0 00 5 155 20 0 00 0 00 ADDITIONAL INFORMATION SECTION CALCULATED NET REIMB FOR
149. 00 25817 3653 000 000 386 2000 154255 Py Red Nat Remb 5164255 Feb 7 2007 afe 12 18 54 PM The reports that are generated based on the outpatient xxZ Ambulance Blend report template are Inpatient Ambulance Blend Effective 04 01 02 12Z Outpatient Ambulance Blend Effective 04 01 02 13Z e SNF Ambulance Blend Effective 04 01 02 22Z e SNF Ambulance Blend Effective 04 01 02 23Z e ASC and ASC Fee Schedule Ambulance Blend Effective 04 01 02 83Z Critical Access Hospital Ambulance Blend Effective 04 01 02 85Z A brief description of these reports is provided in the following sections 5 5 1 Inpatient Ambulance Blend Effective 04 01 02 12Z The Inpatient Ambulance Blend Effective 04 01 02 12Z report summarizes hospital inpatient ambulance services reimbursed under the ambulance fee schedule blended payment which is effective for services provided on or after April 1 2002 The items reported on the Inpatient Ambulance Blend Effective 04 01 02 12Z report are included on the Medicare Cost Report User Manual Outpatient Reports February 2009 Version No 2 0 5 24 Provider Statistical and Reimbursement System 5 5 2 Outpatient Ambulance Blend Effective 04 01 02 13Z The Outpatient Ambulance Blend Effective 04 01 02 13Z report summarizes hospital outpatient ambulance services reimbursed under the ambulance fee schedule blended payment which is effective for services provided on or
150. 000 Outlier 0 00 Racpt Dt 0502 06 PP Claim No duo TO 125700 DSH UP 441 77 Hold Harm 000 Cash Dedect Paid Ot 05 17 04 Pricer Rts Cot o IME Teach Ad 157 18 OSH 2864 Blood Deduct Service From 03 23 04 nfts B nd ina No det lo Fan New Tech 000 me 1039 Coins Service Thru 03 23 04 Processor ID 14500 0302 o 8300 PF ECT 209 apns go NF Med Days 1 035 0 13400 Toul 24mm rem zorsa MSP Pass Thre Recon 0220 e 521200 maa pusa Omer Adjs 0304 515500 Net Raimb osso O 5132700 0730 G 130 00 TOTAL 1 6 0308 Patak Na PEEKM BH Freq 1 RevCode Units Charges Operating Capital Payment DCN 2040874755004 Trans Type 0121 1 89300 Pent Catr a 131000000000 Dschrg Patnt Ce 1 ms o nG sp 000 HSP 000 Gross Remb Med Rerd i 293000000000 Dzchrg Patnt Stat Yes as o 24940 gt 4568 63 FSP 4019 iess HC Name 2766940908 DRG CMG Cd EI us To 1560 Outlier 000 Outlier 0 00 Racpt Dt 0505 06 PP Claim No aor To Tana DSH LP 529468 Hold Harm 000 Cash Detect Paid ot 05 19 04 Pricer Rte Cot o IME Teach Ad 0485 OSH 19 10 Blood Deduct Service From 03 30 04 anit band inc No 0905 o 228 00 New Tech ME Coins Service Thru 03 31 04 Processor ID 14000 306 0 1010 PF ECT Spins MSP Med Days 1 0307 O 7200 Total 96815 Total MSP Pass Thre Racon 0402 o 477 00 Omer Adjs TOTAL 5210487 Nagtaka Monthly Totals for PETERBORO GENERAL HOS
151. 00007 PETERBORO GENERAL HOSPITAL STATISTIC SECTION CLAIMS CHARGE SECTION REV CODE DESCRIPTION 0252 DRUGS NONGENERIC 0305 LAB HEMATOLOGY 0341 NUC MED DX 0636 DRUGS DETAIL CODE TOTAL COVERED CHARGES REIMBURSEMENT SECTION GROSS REIMBURSEMENT LESS CASH DEDUCTIBLE BLOOD DEDUCTIBLE COINSURANCE NET MSP PAYMENTS PSYCH REDUCTION NET REIMBURSEMENT ADDITIONAL INFORMATION SECTION CLAIM INTEREST PAYMENTS Feb 1 2007 SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 04 12 31 04 No Data Requested No Data Requested No Data Requested UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES 1 4 03 1 58 00 2 2 526 00 2 686 10 EI 3 484 13 3 263 29 200 00 0 00 792 04 2 198 22 0 00 73 03 0 00 1 7 57 07 PM User Manual February 2009 Version No 2 0 Outpatient Reports 5 11 Exhibit 5 4 Provider Statistical and Reimbursement System Outpatient xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Payment Reconciliation Detail Report Template First Page Program ID REDESIGN Service Month End 01 31 04 Report Run Date 02 07 07 Provider FYE 12 31 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PAYMENT RECONCILIATION REPORT OUTPATIENT ALL OTHER MSP LCC Provider Number 100007 PETERBORO GENERAL HOSPITAL Patet Nec DCN Pint Col d Med Rord amp HC Nu Recpt Dt Paid Ot Service From Service Thru Pa
152. 0251 0324 71010 1 1837 000 000 19500 41 69 000 Coles MSP 200 000 000 2000 000 20 84 000 0 00 i399 00 5359 SODO Lima tam Fnacied Romi Coins i399 99 55339 000 MSP Poe Lie item Forted Racon Rad Raimb Coins 20 85 000 sam 000 15 62 0 00 20527 000 MSP Pac Unemem Facted Recon Red Remb Coins 000 200 2025 000 25 San ad x v 5 sar lad N x Pym Ind Pyat Ind 9 1 Tos Inci o o 0 E 2 zi Page 1 Report 0044202 Report Type 123P Paid Dates 01 01 04 to 10 01 06 Reimbursements GAPC 7315 PLUS Outlier 09 Gross Reimb 7315 Less Cash Deduct 000 Blood Deduct 000 Coins 19 16 MSP 000 MSP Recon 002 Other Adis 000 Psyc Red Net Reimb 5309 GAPC 7315 PLUS Outlier i000 Gross Reimb 7315 Less Cash Deduct 000 Blood Deduct sona Coins 19 16 MSP 000 MSP Recon 000 Other Adjs sooo Psyc Red Net Reimb 35399 GAPO 28307 PLUS Outlier 200 Gross Remb 28307 LESS Cash Deduct 000 Blood Deduct 000 Coins 7780 MSP son MSP Recon 200 Other Adis 000 Psyc Rad Net Reimb 20527 GAPC 43 87 PLUS Outiier 009 MSP Cash Deduct 0 00 MSP Blood Deduct 006 MSP Coins 0 00 Claim interest coc Elected Coins 0 00 Claim Report Spats E MSP Cash Deduct 0 00 MSP Blood Deduct 0 00 MSP Coins 0 00 Claim eres 0 00 Elected Coins 0 00 Cl
153. 028 PARROTHEAD MEDICAL CENTER Service Period 01 01 1999 12 31 1999 TOTAL 01 01 2000 12 31 2000 TOTAL 01 01 2004 12 31 2004 TOTAL Report Type 831 Totals for PARROTHEAD MEDICAL CENTER Units TOTAL a Feb 19 2007 238145 832 77 0 00 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PAYMENT RECONCILIATION REPORT ASC AND ASC FEE SCHEDULE AFTER 12 90 Service Period and Report Type Totals Stndra Units a Gross Cash Blood Coins MSP Une item Orth ng duc edu Amt 7 122805 441755 000 000 2456 000 HINA PIAS Sinara we owe SS ae ge Sat 1G 115340 41522 000 000 2068 000 SIBASA 1 08259 Sinara Gos Ch Blood Une item wu eee aw p Dat Oe OE 0 000 000 000 000 000 000 000 000 Charges Gross Relmb Cash Deduct Page 3 Report 0144202 Report Type 831 Paid Dates 01 01 80 to 10 01 06 Reimbursements Additional Information Gross Reimb 417 55 MSP Cash Deduct 0 00 LESS MSP Blood Deduct 0 00 MSP Coins 000 Cash Deduct 000 Claim Interest 000 Blood Deduct 0 00 Stnded Ovrhd Amt 536496 Coins 245 61 MSP 000 Net Remb 17194 Gross Reimb 415 22 MSP Cash Deduct 0 00 LESS MSP Blood Deduct 000 MSP Coins 000 Cash Deduct 000 Cisim Interest 000 Blood Deduct 0 00 Stndrd Ovrhd Amt 1 082 59 Coins 230 68 MSP 0 00 Net Reimb 518454 Gross Reimb 000 MSP Cash Deduct 0 00 LESS MSP Blood
154. 056X All revenue code lines Total Part A and Part B visit count related to med soc serv where the first three positions 056 are rolled up during SCI C PEP episode User Manual February 2009 Version No 2 0 Report Data B 144 Provider Statistical and Reimbursement System Report Type Data Element Description 399 SCIC PEP 057X All revenue code lines Total Part A and Part B visit count related to home health aide where the first three positions 057 serv during SCIC PEP episode are rolled up 399 SCIC PEP 058X All revenue code lines Part B Other Visits with outlier where the first three positions 058 are rolled up 399 SCIC PEP 059X All revenue code lines Total Part A and Part B visit count for all disciplines for where the first three positions 059 SCIC PEP episodes are rolled up 399 SCIC PEP 060X All revenue code lines Part B oxygen charges with outlier where the first three positions 060 are rolled up 399 SCIC PEP 062X All revenue code lines Part B medical supplies charges with outlier where the first three positions 062 are rolled up 399 SCIC PEP 0623 Displays by itself Part B surgical dressings charges with outlier 399 SCIC PEP All other Rev Codes display All other Part B revenue code charges as they come in on the claim they do not roll up 399 SCIC 0023 Does not display These f
155. 057X All revenue code lines where the first three positions 057 are rolled up These fields are not populated on this report 339 PEP 058X All revenue code lines where the first three positions 058 are rolled up These fields are not populated on this report 339 PEP 059X All revenue code lines where the first three positions 059 are rolled up These fields are not populated on this report 339 PEP 060X All revenue code lines where the first three positions 060 are rolled up These fields are not populated on this report 339 PEP 062X All revenue code lines where the first three positions 062 are rolled up These fields are not populated on this report 339 PEP 0623 Displays by itself These fields are not populated on this report 339 PEP All other Rev Codes display as they come in on the claim they do not roll up These fields are not populated on this report 339 SCIC PEP 0023 Does not display These fields are not populated on this report 339 SCIC PEP 027X All revenue code lines where the first three positions 027 excluding 0274 are rolled up These fields are not populated on this report 339 SCIC PEP 0274 Displays by itself These fields are not populated on this report 339 SCIC PEP 029X All revenue codes lines where the
156. 06 HOME HEALTH PPS PART B EPISODES Report amp OD44228 Report Run Date 02 05 07 Report Type 329 Provider FYE 12 31 Provider Number 137008 MOBILE NURSE SERVICES SERVICES APPLIED FOR THE PERIODS 01 01 2004 12 31 2004 TOTAL SERVICES REV CODE DESCRIPTION 057X HOME HEALTH AIDE 12 600 00 0 0 00 0 000 0 0 00 0 0 00 12 600 00 0623 SURGICAL DRESSINGS 0 552 86 0 0 00 0 0 00 0 0 00 0 0 00 0 552 86 TOTAL COVERED SERVICES 27 2 951 42 0 0 00 0 0 00 0 0 00 0 0 00 27 2 951 42 REIMBURSEMENT SECTION FULL EPISODES LUPA EPISODES PEP ONLY EPISODES SCIC ONLY EPISODES SCIC WITHIN A PEP TOTAL EPISODES WITHOUT OUTLIER 4 0 0 0 0 4 HIPPS REIMBURSEMENT WITHOUT OUTLIER 14 884 25 0 00 1 661 47 0 00 0 00 16 545 72 EPISODES WITH OUTLIER 0 0 0 0 0 0 HIPPS REIMBURSEMENT WITH OUTLIER 0 00 0 00 0 00 0 00 0 00 0 00 OUTLIER REIMBURSEMENTS 0 00 0 00 0 00 0 00 0 00 0 00 PROSTHETIC ORTHOTIC DEVICES 0 00 0 00 0 00 0 00 0 00 0 00 DME 0 00 0 00 0 00 0 00 0 00 0 00 OXYGEN 0 00 0 00 0 00 0 00 0 00 0 00 OTHER FEE REIMBURSEMENTS 0 00 0 00 0 00 0 00 0 00 0 00 GROSS REIMBURSEMENT 14 884 25 0 00 1 661 47 0 00 0 00 16 545 72 LESS DEDUCTIBLES 0 00 0 00 0 00 0 00 0 00 0 00 Feb 5 2007 2 9 59 56 AM User Manual Outpatient Reports February 2009 Version No 2 0 5 41 Provider Statistical and Reimbursement System Exhibit 5 22 Outpatient xxM xx9 Medicare Secondary Payer Lower Cost
157. 1 VACCINE ADMIN 1 15 00 2 30 00 TOTAL COVERED CHARGES 2 533 00 d 128 00 REIMBURSEMENT SECTION GROSS REIMBURSEMENT 33 00 128 00 LESS CASH DEDUCTIBLE 0 00 0 00 BLOOD DEDUCTIBLE 0 00 0 00 COINSURANCE 0 00 0 00 NET MSP PAYMENTS 0 00 0 00 PSYCH REDUCTION 0 00 NET REIMBURSEMENT 33 00 128 00 ADDITIONAL INFORMATION SECTION CLAIM INTEREST PAYMENTS 0 00 0 00 Feb 5 2007 d 10 21 53 AM User Manual Outpatient Reports February 2009 Version No 2 0 5 26 Provider Statistical and Reimbursement System Exhibit 5 13 Outpatient xx2 Vaccines Payment Reconciliation Detail Report Template Program ID REDESIGN Service Month End 01 31 05 Report Run Date 02 19 07 Provider FYE 12 31 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PAYMENT RECONCILIATION REPORT OUTPATIENT PART 8 VACCINE Page 2 Report Type 132 Provider Number 192305 MOTHER MARY ESRD Report 0044202 Paid Dates 01 01 80 to 10 01 06 EN Cc eeen Patrt Nm EDGII Bil Freg t Rev Gross Cash Blood Une Item Gross Relmb 3500 MSP Cash Deduct 000 DCN 20599769236704 Trans Type Code HCPCS Units Charges pb Deduct Deduct COS MSP et Remb age MSP Blood Deduct 020 Ptr Cntri d 378000000000 Processor ID 14000 0636 30732 90 00 80 00 0 00 0 00 0 00 0 00 80 00 MSP Coins 000 Med Rerd 0977 Goode 15 00 15 00 2 00 000 0 00 0 00 15 09 Cash Deduct 000 Claim Interest 000 HIC Num 155367884A AA PT
158. 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 142 Outpatient Other Vaccines Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 TO00 T999 M300 M399 R300 R399 Yes 145 Outpatient Other Fee Reimbursed Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 No 18A Swing Bed SNF MSP LCC Inpatient Swing Bed SNF or CAH Hospital Group U001 U999 W001 W999 Y001 Y999 2300 2399 1300 1399 Yes User Manual February 2009 Version No 2 0 Report Details A 6 Provider Statistical and Reimbursement System Report Service Provider Provider Cost Report Type Report Name Category Type s Number Range Yes No 180 Swing Bed SNF Inpatient Swing Bed SNF U001 U999 Yes or CAH Hospital W001 W999 Y001 Y999 2300 2399 1300 1399 21A SNF Inpatient Part A Inpatient SNF 5000 6499 Yes MSP LCC 210 SNF Inpatient Part A PPS Inpatient SNF 5000 6499 Yes 22A SNF Inpatient Part B Outpatient SNF 5000 6499 No MSP LCC 22P SNF Outpatient OPPS Outpatient SNF 5000 6499 Yes 22Z SNF Ambulance Blend Outpatient SNF 5000 6499 Yes Effective 04 01 02 220 SNF Inpatient Part B Cost Outpatient SNF 5000 6499 Yes R
159. 2 Report Run Date 02 19 07 Report Type 329 Provider FYE 12 31 Pald Dates 01 01 80 to 10 01 06 Provider Number 137008 MOBILE NURSE SERVICES EN S IA Reimbursements Adational information HEIL a Gross HIPPS Reims 3 91975 Deductibles 0 00 jc FEN gis tako d C RevCode HCPCS FeeType Unis Visits Charges Cros fee 8 ved oat papi Pera Cntri d 249000000000865F WAY Pricer Rtn Cd 5 3425 6015 500 00 0 Claim Interest 020 Med Rerd d 14000 9551 0154 7 875 00 009 Outer 050 Patient CASA 6840 HIC Num 1 Groot Fee Remb 000 HIPPS CODE RecptDt o TOTAL 1 375 00 000 Gross Reimb 4105375 WIPPS WGHT Paid Dt LESS PAYMENT TYPE FULL EPISODE Service From Service Thr Deductibles 0 09 Coins 0 00 MSP 000 MSP Recon sano Other Ads 000 Net Reimb 3 089 75 Monthly Totals for MOBILE NURSE SERVICES for service month end 9 30 04 TOTAL BY TYPE OF EPISODE Total Covered Charges 5137520 Full Episodes LUPA PEP SOCIPEP sac Total Total Gross Remb 3 049 75 Visits d LESS Covered Charges 1 375 00 0 00 0 00 0 00 0 90 1 375 00 Deductibles 0 00 HIPPS Reimb 3 049 75 0 00 000 0 00 0 00 3 009 75 Coinsurance 000 Out 0 00 0 00 0 00 MSP 0 00 tler MSP Reconciliation 0 00 Other Adjustments 0 00 FEE REIMBURSED SERVICES vest Bese PKO Oxygen Other Fee Total Covered Charges sana 0 00 0 00 0 00 61137500 Gross Fee Reimb 0 00 0 00 0 00 0 0 Feb 19 2007 ne 9 12 25 AM The repo
160. 2 CT SCAN BODY 0 0 00 2 2 898 00 o 0 00 0 0 00 0390 BLOOD STOR PROC 0 0 00 2 436 00 0 00 0 0 00 Feb 5 2007 1 9 51 23 AM User Manual Inpatient Reports February 2009 Version No 2 0 4 16 Provider Statistical and Reimbursement System Exhibit 4 13 Inpatient 18x and 21x Provider Summary Report Template Page 2 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page 2 Paid Dates 01 4 THRU 10 01 05 SWING BED SNF Report OD44202 Report Run Date 02 05 07 Report Type 160 Provider FYE 12 31 Provider Number TOZ300 SNOW BIRD HOSPITAL SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 04 03 21 04 04 01 04 06 20 04 07 01 04 03 20 04 10 01 04 12 31 04 REV CODE DESCRIPTION UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES 0402 ULTRASOUND 3 1 847 00 2 1215 00 o 0 00 0 0 00 0410 RESPIRATORY SVC 75 6 504 00 559 555 071 00 0 0 00 0 0 00 0420 PHYSICAL THERP 1 061 72 009 00 1 437 38 450 00 o 0 00 0 0 00 0430 OCCUPATION THER 762 52 221 00 1 048 7292400 o 0 00 0 0 00 0440 SPEECH PATHOL 1 357 00 8 1 733 00 o 0 00 0 0 00 0460 PULMONARY FUNC 14 700 00 12 500 00 o 0 00 0 0 00 0480 CARDIOLOGY 3 2 014 00 0 0 00 o 0 00 0 0 00 0730 EKG ECG 4 958 00 3 741 00 o 0 00 0 0 00 0921 PERI VASCUL LAB 5 3 330 00 7 3 545 00 o 0 00 0 0 00 0998 BARBER BEAUTY 0 0 00 0 0 00 o 0 00 0 0 00 TOTAL ANCILLARY 6 854
161. 2 Primary First Name Provider Field must not be null Error E112 No primary field First Name entered Please enter a primary First Name to proceed E113 Primary Last Name Provider Field must not be null Error E113 No primary field Last Name entered Please enter a primary Last Name to proceed E114 Primary Phone Provider Field must not be null Error E114 No primary field Phone entered Please enter a primary phone number to proceed E115 Primary Phone Provider Field must be 10 digits Error E115 This is not a field valid Primary phone number Please reenter a valid 10 digit phone number to proceed E118 Primary Fax field Provider If data is provided entry Error E118 This is not a must be 10 digits valid primary Fax Please reenter a valid 10 digit fax number to proceed E121 Primary E mail field Provider Field must not be null Error E121 No primary E mail entered Please enter a Primary E mail address to proceed E122 Primary E mail field Provider Field must contain the Error E122 Please enter symbol a valid primary e mail address E124 Secondary Phone Provider If data is provided entry Error E124 This is not a field must be 10 digits valid Secondary phone number Please reenter a valid 10 digit phone number to proceed E127 Secondary Fax Provider If data is provided entry Error E127 This is not a field must be 1
162. 20 Claim interest s020 1213 54 PM User Manual February 2009 Version No 2 0 Inpatient Reports 4 12 Provider Statistical and Reimbursement System Exhibit 4 11 Inpatient 115 Payment Reconciliation Detail Report Template Last Page PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page 2 Service Month End N A INPATIENT FEE REIMBURSED Report OD44202 Report Run Date 02 07 07 Report Type 115 Provider FYE 12 21 Paid Dates 01 01 04 to 10 01 06 Provider Number T00007 PETERBORO GENERAL HOSPITAL Service Period and Report Type Totals Service l eriod Reimbursements Additional information 01 01 2004 01 01 2006 Uns Charges HCPCS Remb Gross Remb 3705 MS Cash Deduct 000 TOTAL 35 8 002 41 3705 LESS MSP Blood Deduct soso NE MS Coins 0 00 Cash Deduct 000 Claim interest soso Stood Deduct 000 Cons 0 00 MSP 205 Net Reind 37 05 Report Type 115 Totals for PETERBORO GENERAL HOSPITAL Reimbursements Additional Information Units Charges HCPCS Remb Gross Remb 3705 0 00 TOTAL 33 8 002 41 3705 Less 0 00 m 020 Cas Deduct 000 0 00 Blood Deduct 0 00 Cons 0 00 MSP 2 00 Nat Reim 37 05 Feb 7 2007 2 12 13 54 PM 4 2 2 Inpatient Part A MSP LCC 11A The Inpatient Part A MSP LCC 11A report is a supplemental report to the Inpatient Part A 110 report For providers on PIP Part A the interim payments included on the cost re
163. 2009 Version No 2 0 Error Messages C 36 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message E046 Load Control CMS FI MAC You must select either PDF Error E046 No report Miscellaneous Report Admin or CSV as the report format format was selected Request Select to continue Please choose a report Format Page format before continuing E047 Your Request Name All The Your Request Name Error E047 Your Field field cannot be null Request Name is not entered Please enter a request name to proceed E047 FI MAC Provider FI MAC Admin The Your Request Name Error E047 Your Requests Your field cannot be null Request Name is not Request Name entered Please enter a Textbox request name to proceed E047 Load Control CMS FI MAC The Your Request Name Error E047 Your Confirmation Page Admin field cannot be null Request Name is not after selecting a entered Please enter a format type from the request name to miscellaneous Report proceed Request page E066 Include 110 DRG All If the box is checked service Error E066 The DRG Section type selected must be All Section is only valid with or Inpatient Report Group selections of All must be 11x or Report Type Inpatient 11x or must be 110 110 E069 Change Periods with All All date field entries must Error E069 Service Specific Dates
164. 29 TOTAL 043X All revenue code lines Part B occupational therapy count without outlier where the first three positions 043 are rolled up 329 TOTAL 044X All revenue code lines Part B speech count without outlier where the first three positions 044 are rolled up 329 TOTAL 055X All revenue code lines Part B nursing count without outlier where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 111 Provider Statistical and Reimbursement System Report Type Data Element Description 329 TOTAL 056X All revenue code lines Part B med soc serv without outlier where the first three positions 056 are rolled up 329 TOTAL 057X All revenue code lines Part B home health aide count without outlier where the first three positions 057 are rolled up 329 TOTAL 058X All revenue code lines Total Part B visits without outlier where the first three positions 058 are rolled up 329 TOTAL 059X All revenue code lines Total Part B visits without outlier where the first three positions 059 are rolled up 329 TOTAL 060X All revenue code lines Total Part B Oxygen charges without outlier where the first three positions 060 are rolled up 329 TOTAL 062X All revenue code lines Total Part B Med Supplies charges without outlier where the first three positi
165. 290 HIPPS CODE Recpt Dt 01 27 05 PartB Visits Gross Reimb s28TEDD HIPPS WGHT Paid Dt 01 31 05 LESS PAYMENT TYPE RAP Service From 0972404 CANCEL METHOD N A Service Thru 03 24 04 Deductibles 000 Coins 0 00 MSP 0 00 MSP Recon 0 00 Other Adjs 0 00 Net Relmb 2816 90 Monthly Totals for MOBILE NURSE SERVICES for service month end 6 30 04 Count Reimbursement TOTAL INITIAL RAP 5281690 RAP CANCELLED BY CLAIM 000 RAP AUTO CANCELLED 000 RAP PROVIDER CANCELLED RAP Fl CANCELLED 0 0 00 TOTAL CANCELLED RAPS 0 90 mee TOTAL RAPS OUTSTANDING GROSS REIMBURSEMENT NET REIMBURSEMENT 2816 90 Feb 19 2007 nde 9 10 23 AM The reports that are generated based on the outpatient 322 332 Home Health Agency report template are Home Health PPS Part B RAP 322 Home Health PPS Part A RAP 332 A brief description of these reports is provided in the following sections 5 10 1 Home Health PPS Part B RAP 322 The Home Health PPS Part B RAP 322 report summarizes Medicare Part B Requests for Anticipated Payments RAP activity The items reported on the Home Health PPS Part B RAP 322 report are not to be included on the Medicare Cost Report 5 10 2 Home Health PPS Part A RAP 332 The Home Health PPS Part A RAP 332 report summarizes Medicare Part A Requests for Anticipated Payments RAPs activity The items reported on the Home Health PPS Part A RAP 332 report are not to be inc
166. 32M PROSTHETIC ORTHOTIC DEVI CES This is the Part B MSP LCC information 32M DME This is the Part B MSP LCC information 32M OXYGEN This is the Part B MSP LCC information 32M OTHER FEE REIMBURSEMENTS This is the Part B MSP LCC information 32M GROSS REIMBURSEMENT This is the Part B MSP LCC information 32M DEDUCTIBLES This is the Part B MSP LCC information 32M COINSURANCE This is the Part B MSP LCC information 32M NET MSP PAYMENTS This is the Part B MSP LCC information 32M MSP RECONCILIATION This is the Part B MSP LCC information 32M OTHER ADJUSTMENTS This is the Part B MSP LCC information 32M NET REI MBURSEMENT This is the Part B MSP LCC information 32M CLAIM INTEREST PAYMENTS This is the Part B MSP LCC information Rev Code PDF Revenue Code CSV Column This is the Part B MSP LCC information User Manual February 2009 Version No 2 0 Report Data B 137 Provider Statistical and Reimbursement System Report Type Data Element Description 32M 0023 Does not display This is the Part B MSP LCC information 027X All revenue code lines where the first three positions 027 excluding 0274 are rolled up 0274 Displays by itself 029X All revenue code lines where the first three positions 029 are rolled up 042X All revenue code lines where the first three positions 042 are rolled up 043X All revenue code lines where the first three positio
167. 339 PEP 059X All revenue code lines where the first three positions 059 are rolled up These fields are not populated on this report 339 PEP 060X All revenue code lines where the first three positions 060 are rolled up These fields are not populated on this report 339 PEP 062X All revenue code lines where the first three positions 062 are rolled up These fields are not populated on this report 339 PEP 0623 Displays by itself These fields are not populated on this report 339 PEP All other Rev Codes display as they come in on the claim they do not roll up These fields are not populated on this report 339 SCIC PEP 0023 Does not display These fields are not populated on this report 339 SCIC PEP 027X All revenue code lines where the first three positions 027 excluding 0274 are rolled up These fields are not populated on this report 339 SCIC PEP 0274 Displays by itself These fields are not populated on this report 339 SCIC PEP 029X All revenue codes lines where the first three positions 029 are rolled up These fields are not populated on this report User Manual February 2009 Version No 2 0 Report Data B 124 Provider Statistical and Reimbursement System Report Type Dat
168. 38 Dates by entry for Provider ID Provider s To contains a non numeric Dates character or is not in MM DD YYYY format All Only numeric characters Error E038 Service Date s E038 entry for Provider ID contains a non numeric character or is not in MM DD YYYY format User Manual February 2009 Version No 2 0 Error Messages C 13 Provider Statistical and Reimbursement System Form Field User Type Validation Error Warning Message ID All Entry must be in MM DD YYYY Error E038 Service Date s E038 format entry for Provider ID contains a non numeric character or is not in MM DD YYYY format All Month Day and Year values Error E001 Service Date s E001 must be valid entry for Provider ID contains an invalid month day and or year All Entry must be greater than or Error E312 Service dates for E312 equal to corresponding Provider ID do not have a Service Period From Date valid date range From from date To to date All Entry must be less than the Error E092 Service Periods E092 next Service Period From Date overlap and or are not this assures chronological chronological for Provider service periods and that there ID is no overlapping service periods Paid Date From All Field must not be null Error E042 Paid Date s E042 Date entry contains a non numeric character or is not in MM DD
169. 399 PEP OXYGEN Part B Oxygen for PEP 399 PEP OTHER FEE REIMBURSEMENTS Part B Other Fee for PEP 399 PEP GROSS REIMBURSEMENT Part B gross reimbursement for PEP 399 PEP DEDUCTIBLES Part B Deduct for PEP 399 PEP COINSURANCE Part B Coins for PEP 399 PEP NET MSP PAYMENTS Part B MSP Recon for PEP 399 PEP MSP RECONCILIATION Part B Net MSP Payment for PEP 399 PEP OTHER ADJ USTMENTS Part B Other Adjust for PEP 399 PEP NET REIMBURSEMENT Part B net reimbursement for PEP 399 PEP CLAIM INTEREST PAYMENTS Part B Claim Interest Payments for PEP User Manual February 2009 Version No 2 0 Report Data B 160 Provider Statistical and Reimbursement System Report Type Data Element Description 399 SCIC PEP EPISODES WITHOUT Part B of Episodes w o outlier for SCI C PEP OUTLIER 399 SCIC PEP HIPPS REIMBURSEMENT Part B HIPPS reimbursement without outlier for SCI C PEP WITHOUT OUTLIER 399 SCIC PEP EPISODES WITH OUTLIER Part B of Episodes with outlier for SCIC PEP 399 SCIC PEP HIPPS REIMBURSEMENT Part B HIPPS Reimb with outlier for SCI C PEP WITH OUTLIER 399 SCIC PEP OUTLIER REIMBURSEMENTS Part B outlier reimb for SCIC PEP 399 SCIC PEP PROSTHETI C ORTHOTIC Part B P amp O for SCIC PEP DEVICES 399 SCIC PEP DME Part B DME for SCIC PEP 399 SCIC PEP OXYGEN Part B Oxygen for SCI C PEP 399 SCIC PEP OTHER FEE Part B Other Fe
170. 4 4 Bill Freq Trans Type Dschrg Patet Cd Dschrg Patet Sut DRG CMG Ca PIP Caim Bets Exhstd Ind Processor iD Bill Frag Trans Type Dschrg Patet Cd Dschrg Patet Sat DRG CMG Co PIP Calm Bets Exista Ind Processor iD ont 0250 0255 0253 Baga Bee d TOTAL Oucharge Count 2 PAYMENT RECONCILIATION REPORT SWING BED SNF n 19 7 445 M N eiis o TOTAL Charges RUGS Rate 51325100 000 1 695 00 200 2475 00 000 252424 000 2 534 00 200 5132 00 000 443 00 200 355 00 000 478 00 200 55400 2500 2 272 09 no 6933 09 200 550400 200 55 00 OD 40 197 24 Charges RUGS Rate 8 824 00 0 00 2517 00 0 00 355 00 0 00 532800 0 00 263 00 0 00 2 503 00 0 00 2 103 00 0 00 5201400 000 19 023 00 1 165 85372024 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Reimbursements Gross Remb LESS Cam Deduct Blood Deduct Net Reimd Gross Reimb LESS Cam Deduct Blood Deduct Net Reid Reimbursements Gross Remb Cam Deduct Blood Decuct Net Reind 16 590 00 0 00 0 00 109 50 1029 HUS 11 060 00 0 00 0 00 0 00 2000 1106000 27 55000 000 000 10850 000 27 54050 Page 1 Report 0044202 Report Type 150 Paid Dates 01 01 04 to 10 01 06 Additional Information MS Cash Dedisct MS Blood Deduct MS Coins Calc Reimb PIP Actual Cim Pymnts PIP Claim Interest
171. 437837 DRG CMG Wgt Wgt Dschi Net Reims SZ sen pisa ORG Wit Fretn DRG Wgt Frct Dschegs Report Type 11A Totals for PETERBORO GENERAL HOSPITAL Operating Capital Payment Additional information Units Charges HS 000 HSP 0 00 Gross Reimb 1358633 MS Cash Dedect 0 00 Med Days 2 Discharge Count 2 TOTAL 2 5920795 FsP 1141770 FSP 110529 un MS Blood Deduct 0 00 Outier 000 Outr 0 00 MS Coins soco DSH UP 573645 Hold Harm 0 00 Cash Dedect 87600 Cak Reimb PIP 0 00 IME Teach Adj 26203 DSH 4774 Blood Deduct 020 Actual Cim Pymnts PP New Tech 020 IME 1732 Coins 020 Claim interest soso IPF ECT 000 Extptes 0500 MSP 757635 IRF Penalty 0 00 MS Pass Thru Recom 050 LTCH Short Stay Ostir s020 Totat 1 170 15 Tota nit ad Omer Adjs 437837 Cap FSP 100 1 105 09 Cm Cap Ostir 100 s020 With SESI onc cw6 wet Wigt Dschrgs Dschrg Freta ORG Wt Fretn DRG Wigt Frctn Dschegs Feb 7 2007 2 123454 PM The reports that are generated based on the Inpatient 11x report template are e Inpatient Part A MSP LCC 11A npatient Long Term Care Part A PPS Interim Bills 11T npatient Long Term Care Part A PPS 11S e Inpatient Rehabilitation PPS Interim Bills 11K npatient Part A Managed Care 118 e Inpatient Rehabilitation Part A PPS 11R e Inpatient PPS Interim Bills 119 e Inpatient Part A 110 e Inpatient Psych Part A PPS 11U e Inpatient Psych
172. 5 Error preparing to get E195 Report Results Report Results amp arg1 System Error PS amp R Error retrieving the Report Error E196 Error retrieving E196 Results Report Results amp arg1 System Error PS amp R Error while preparing to get Error E197 Error preparing to get E197 Load Control Main records Load Control Main amp arg1 System Error PS amp R Error retrieving Load Control Error E198 Error retrieving Load E198 Main records Control Main amp arg1 System Error PS amp R Error while preparing to get Error E199 Error preparing to get E199 Load Control Hold records Load Control Hold amp arg1 System Error PS amp R Error retrieving the Load Error E200 Error retrieving Load E200 Control Hold records Control Hold amp arg1 System Error PS amp R Error while preparing to get Error E201 Error preparing to get E201 Load Control Release records Load Control Rlse amp arg1 System Error PS amp R Error retrieving the Load Error E202 Error retrieving Load E202 Control Release records Control Rlse amp arg1 System Error PS amp R Error while preparing to get Error E203 Error preparing to get E203 Load Detail Hold reports Load Detail Hold Report amp arg1 User Manual February 2009 Version No 2 0 Error Messages C 25 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message ID
173. 60 4 for a complete listing of revenue codes 110 DESCRIPTI ON The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 110 TOTAL ACCOMODATI ONS This category may include provider liable days that are non covered days This category may be used to prorate the Medicare Days field for cost reporting purposes 110 TOTAL ANCILLARY All Medicare covered charges associated with revenue codes designated as ancillary 110 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as routine and ancillary 110 HOSPITAL SPECIFIC This line plus any federal specific amounts are the total DRG amounts other than outlier 110 FEDERAL SPECIFIC This line plus any hospital specific amounts are the total DRG amounts other than outlier 110 OUTLIER Summarizes cost outlier payments Value code 17 made under the Prospective Payment System 110 DSH LIP The DSH LIP amount value code 18 shown on the PS amp R report represents interim payments calculated by the PPS pricer program For cost reporting purposes the DSH LIP amount must be recomputed for qualifying hospitals User Manual Report Data February 2009 Version No 2 0 B 1 Provider Statistical and Reimbursement System Report Type Data Element Description 110 IME TEACHING AD Indirect medical education Teaching adj
174. 755 CHARGES The charges applicable to each revenue code 755 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 755 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 755 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 755 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 755 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 755 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 755 COINSURANCE The actual coinsurance amount from the paid claim record 755 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 755 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 84 Provider Statistical and Reimbursement System
175. 765 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 765 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 835 CLAIMS Currently this field has no cost report usage 835 UNITS The number of units applicable to each revenue code 835 CHARGES The charges applicable to each revenue code 835 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 835 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes User Manual February 2009 Version No 2 0 Report Data B 85 Provider Statistical and Reimbursement System Report Type Data Element Description 835 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 835 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 835 CASH DEDUCTIBLE The actual cash deductible amount from the paid
176. 799 34A Home Health Part B Outpatient HHA 3100 3199 No MSP LCC 7000 8499 9000 9799 34P Home Health Outpatient Outpatient HHA 3100 3199 Yes OPPS Not HHPPS 7000 8499 9000 9799 340 Home Health Part B Outpatient HHA 3100 3199 Yes 7000 8499 9000 9799 342 Home Health Vaccine Outpatient HHA 3100 3199 Yes Part B 10096 Reasonable Cost 7000 8499 9000 9799 345 Home Health Part B Fee Outpatient HHA 3100 3199 No Reimbursed 7000 8499 9000 9799 399 Home Health PPS Part A and Outpatient HHA 3100 3199 Yes Part B Episodes 7000 8499 9000 9799 410 Religious Non Medical Inpatient Religious 1990 1999 Yes Inpatient Part A Nonmedical Inst 6990 6999 71A Clinic Rural Health Outpatient Rural Health 3400 3499 No MSP LCC Clinic 3800 3999 8500 8899 8900 8999 71P Clinic Rural Health OPPS Outpatient Rural Health 3400 3499 Yes Clinic 3800 3999 8500 8899 8900 8999 710 Clinic Rural Health Outpatient Rural Health 3400 3499 Yes Clinic 3800 3999 8500 8899 8900 8999 712 Clinic Rural Health Outpatient Rural Health 3400 3499 Yes Vaccine Part B 10096 Clinic 3800 3999 Reasonable Cost 8500 8899 8900 8999 User Manual February 2009 Version No 2 0 Report Details A 8 Provider Statistical and Reimbursement System Report Service Provider Provider Cost Report Type Report Name Category Type s Number Range Yes No 72A Hospita
177. 90 914 075 99 914 075 99 914 075 99 PROVIDER STATISTICAL SERVICES FOR PERIOD 01 01 05 12 31 05 COUNT 403 ele o o o PROVIDER SUMMARY REPORT HOME HEALTH PPS PART 8 RAP THESE ITEMS ARE NOT TO BE INCLUDED ON THE MEDICARE COST REPORT 914 075 99 0 00 0 00 0 00 0 00 0 00 AND REIMBURSEMENT SYSTEM Page 1 Report OD44228 Report Type 322 SERVICES FOR PERIOD SERVICES FOR PERIOD No Data Requested No Data Requested COUNT REIMB COUNT REIMB 26 49 672 37 49 672 37 49 672 37 9 59 55 AM User Manual February 2009 Version No 2 0 Outpatient Reports 5 45 Provider Statistical and Reimbursement System Exhibit 5 25 Outpatient 322 332 Home Health Agency Payment Reconciliation Detail Report Template PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page 1 Service Month End 06 30 04 HOME HEALTH PPS PART B RAP Report 0044202 Report Run Date 02 19 07 Report Type 322 Provider FYE 12 31 Paid Dates 01 01 80 to 10 01 06 Provider Number 137008 MOBILE NURSE SERVICES intone ee aeration Patr Nm BAROH Bill Freq 2 Gross Fee HIPPS Reimb 5281690 MSPDeductibles 000 DCN 205097091453904 Trans Type Me qeu mM ME pus MSP Coins 0 00 Pont Cntri d 000000000000 Pricer Rtn Ca 5 Claim Interest 000 Med Rerd t Processor ID 14000 Outlier 0 00 Patient CBSA 5600 HIC Nume 289273102A Part A Visits TOTAL Gross Fee Relmb
178. 99 3800 3999 4000 4499 4500 4599 4600 4799 4800 4899 4900 4999 5000 6499 6500 6989 7000 8499 8500 8899 8900 8999 9000 9799 5001 5999 T000 T999 M300 M399 R300 R399 Yes 1000 Consolidated Summary of All Report Groups Inpatient Outpatient All All No User Manual February 2009 Version No 2 0 Report Details A 13 B Report Data Provider Statistical and Reimbursement System The following table contains a list of all the data elements that appear on inpatient or outpatient reports in the PS amp R System The table provides a description of each field along with the report type on which the data element is located Exhibit B 1 Report Data Report Type Data Element Description 110 DISCHARGES This field is only valid for inpatient claims This indicates the number of patients discharged 110 MEDICARE DAYS The provider s hospital routine adults and peds days Note The provider s crosswalk may be used to allocate days for cost reporting purposes 110 CLAI MS Currently this field has no cost report usage 110 UNITS The number of units applicable to each revenue code Note for accommodations revenue codes this may include non covered days 110 CHARGES The charges applicable to each revenue code 110 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section
179. 99 T000 T999 M300 M399 R300 R399 Yes User Manual February 2009 Version No 2 0 Report Details A 11 Provider Statistical and Reimbursement System Report Service Provider Provider Cost Report Type Report Name Category Type s Number Range Yes No 835 ASC and ASC Fee Schedule Outpatient Hospital Group 0001 0999 No Fee Reimbursed 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 S001 5999 TO000 T999 M300 M399 R300 R399 85A Critical Access Hospital Outpatient CAH Hospital 1300 1399 Yes MSP LCC 85Z Critical Access Hospital Outpatient CAH Hospital 1300 1399 Yes Ambulance Blend Effective 04 01 02 850 Critical Access Hospital Outpatient CAH Hospital 1300 1399 Yes 852 Critical Access Hospital Outpatient CAH Hospital 1300 1399 Yes Vaccines Part B 10096 Reasonable Cost 855 Critical Access Hospital Fee Outpatient CAH Hospital 1300 1399 Yes Reimbursed User Manual February 2009 Version No 2 0 Report Details A 12 Provider Statistical and Reimbursement System Report Type Report Name Service Category Provider Type s Provider Number Range Cost Report Yes No 998 Consolidation of Outpatient Claims Excluding MSP LCC Outpatient Hospital Group 0001 0999 1000 1199 1200 1399 1400 1499 1500 1799 1800 1989 2000 2299 2300 2899 2900 2999 3025 3099 3100 3199 3200 3299 3300 3399 3400 3499 3500 37
180. 99 Yes Rehabilitation Facilities OPPS 4500 4599 4800 4899 750 Comprehensive Outpatient Outpatient CORF 3200 3299 Yes Rehabilitation Facilities 4500 4599 4800 4899 User Manual February 2009 Version No 2 0 Report Details A 9 Provider Statistical and Reimbursement System Report Service Provider Provider Cost Report Type Report Name Category Type s Number Range Yes No 752 Comprehensive Outpatient Outpatient CORF 3200 3299 Yes Rehabilitation Facilities 4500 4599 Vaccine Part B 10096 4800 4899 Reasonable Cost 755 Comprehensive Outpatient Outpatient CORF 3200 3299 No Rehabilitation Facilities Fee 4500 4599 Reimbursed 4800 4899 76A Community Mental Health Outpatient CMHC 1400 1499 No Center MSP LCC 4600 4799 4900 4999 76P Community Mental Health Outpatient CMHC 1400 1499 Yes Center OPPS 4600 4799 4900 4999 760 Community Mental Health Outpatient CMHC 1400 1499 Yes Center 4600 4799 4900 4999 762 Community Mental Health Outpatient CMHC 1400 1499 Yes Center Vaccine Part B 4600 4799 10096 Reasonable Cost 4900 4999 765 Community Mental Health Outpatient CMHC 1400 1499 No Center Fee Reimbursed 4600 4799 4900 4999 81A Hospice Non Hospital Based Outpatient Hospice 1500 1799 Yes MSP LCC 81P Hospice Non Hospital Outpatient Hospice 1500 1799 Yes Based OPPS 810 HOSPICE Non Hospital Outpatient Hospice 1500 1799 Yes Based
181. 99 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 75A CLAI MS Currently this field has no cost report usage 75A UNITS The number of units applicable to each revenue code 75A CHARGES The charges applicable to each revenue code 75A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 75A DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 75A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 75A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 75A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 75A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 75A COINSURANCE The actual coinsurance amount from the paid claim record 75A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 75A NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly p
182. AM The reports that are generated based on the outpatient xx2 Vaccines report template are Inpatient Part B Vaccine 122 Outpatient Part B Vaccine 132 Outpatient Other Vaccines 142 SNF Inpatient Vaccine Part B 100 Reasonable Cost 222 SNF Outpatient Vaccine Part B 100 Reasonable Cost 232 Home Health Vaccine Part B 100 Reasonable Cost 342 Clinic Rural Health Vaccine Part B 100 Reasonable Cost 712 Federally Qualified Health Center Vaccine Part B 100 Reasonable Cost 732 Rehabilitation Facility Vaccine Part B 100 Reasonable Cost 742 Comprehensive Outpatient Rehabilitation Facilities Vaccine Part B 100 Reasonable Cost 752 Community Mental Health Center Vaccine Part B 100 Reasonable Cost 762 User Manual Outpatient Reports February 2009 Version No 2 0 5 27 Provider Statistical and Reimbursement System e ASC and ASC Fee Schedule Vaccine Part B 100 Reasonable Cost 832 Critical Access Hospital Vaccines Part B 10096 Reasonable Cost 852 A brief description of these reports is provided in the following sections 5 6 1 Inpatient Part B Vaccine 122 The Inpatient Part B Vaccine 122 report accumulates data applicable to vaccine services reimbursed based on 100 46 of reasonable cost The items reported on the Inpatient Part B Vaccine 122 report are included on the Medicare Cost Report 5 6 2 Outpatient Part B V
183. AP FI CANCELLED This is the RAP cancel by the FI since the HHA did not submit the final RAP within the required timeline for Part B 322 TOTAL CANCELLED RAPS This is the total of all RAP cancel types for Part B 322 TOT RAPS OUTSTANDING This indicates the difference between the initial and final RAP payments for Part B 322 GROSS REIMBURSEMENT This is the gross RAP payment for Part B 322 NET REIMBURSEMENT This is the net RAP payment for Part B 332 COUNT This is the total number of Requests for Advance Payment RAP for PART A 332 REI MB This is the total RAP payment amount for PART A 332 TOTAL INITIAL RAP this is the initial Request for Advance RAP submitted by the HHA for Part A 332 RAP CANCELLED BY CLAIM This is a claim cancel normally part of a claim adjustment for Part A 332 RAP AUTO CANCELLED This is the initial RAP cancel which is made when the final RAP is processed for Part A 332 RAP PROVIDER CANCELLED This is a RAP cancel initiated by the HHA for Part A 332 RAP FI CANCELLED This is the RAP cancel by the FI since the HHA did not submit the final RAP within required timeline for Part A 332 TOTAL CANCELLED RAPS This is the total of all RAP cancel types for Part A 332 TOT RAPS OUTSTANDING This indicates the difference between the initial and final RAP payments for Part A 332 GROSS REI MBURSEMENT This is the gross RAP payment for Part A 332 NET REIMBURSEMENT This is the net RAP payment for Part A User Ma
184. Blood Deduct soso MS Coins 0 00 Claim Interest 020 12 17 55 PM The reports that are generated based on the outpatient xx A Medicare Secondary Payer Lower Cost or Charge MSP LCC report template are e npatient Part B MSP LCC 12A e Outpatient All Other MSP LCC 13A e Outpatient Other MSP LCC 14A e SNF Inpatient Part B MSP LCC 22A e SNF Outpatient MSP LCC 23A e Clinic Rural Health MSP LCC 71A e Federally Qualified Health Center MSP LCC 73A e Rehabilitation Facility MSP LCC 74A e Comprehensive Outpatient Rehabilitation Facilities MSP LCC 75A e Community Mental Health Center MSP LCC 76A User Manual February 2009 Version No 2 0 Outpatient Reports 5 13 Provider Statistical and Reimbursement System e Hospice Non Hospital Based MSP LCC 81A e Hospice Hospital Based MSP LCC 82A e ASC and ASC Fee Schedule MSP LCC 83A e Critical Access Hospital MSP LCC 85A A brief description of these reports is provided in the following sections 5 3 1 Inpatient Part B MSP LCC 12A The Inpatient Part B MSP LCC 12A report is a supplemental report to the Inpatient Part B Cost Reimbursed 120 report For providers on PIP Part A the interim payments included on the Medicare Cost Report are adjusted by the Medicare Secondary Payer Lower Cost or Charge MSP LCC amount The items reported on the Inpatient Part B MSP LCC 12A report ar
185. CE The actual coinsurance amount from the paid claim record 142 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 142 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 142 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 222 CLAIMS Currently this field has no cost report usage 222 UNITS The number of units applicable to each revenue code 222 CHARGES The charges applicable to each revenue code 222 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 222 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 222 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 222 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 222 CASH DEDUCTI BLE The actual c
186. CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 13Z GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 13Z CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 13Z BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 13Z COINSURANCE The actual coinsurance amount from the paid claim record 13Z NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 13Z NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 13Z CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 22Z CLAI MS Currently this field has no cost report usage 22Z UNITS The number of units applicable to each revenue code 22Z CHARGES The charges applicable to each revenue code 22Z GROSS FEE AMT This is an accumulation of 10096 fee reimbursed ambulance services Sorted by trips and mileage 22Z TOTAL AMBULANCE TRIPS Accumulated number of trips from paid claims 22Z TOTAL AMBULANCE MILES Accumulated number of m
187. Checkbox FI MAC Exclude checkbox must not provider s Exclude checkbox Parent be selected must not be selected Provider Save Request as All The Favorite Name field Error E333 Favorite Name E333 Favorite Checkbox selected must contain valid data if the Save Request as Favorite checkbox is selected is not entered Please enter a favorite name to proceed User Manual February 2009 Version No 2 0 Error Messages C 17 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message ID Favorite Name All This field can only contain Error E334 Favorite Name E334 field alpha numeric characters and can only contain alpha the following special numeric characters and the characters _ following special characters Insufficient Room All Users may only save up to Warning W010 The number W010 in the Favorites 100 requests of Saved Favorites limit has Request s Inbox been reached This request will be submitted but not saved Do you wish to continue Favorite Name All The Favorite Name that was Warning W011 A Favorite W011 field entered already exists Request with this name already exists Its saved parameters will be lost Do you wish to continue C 12 Detail Report Request FI MAC Provider Requests The Detail Report Request FI MAC Provider Requests page err
188. Cs can request detail reports directly in the system The FI MAC s PS amp R administrative representative then either approves or denies the request If the request is approved the FI MAC PS amp R administrative representative routes the reports to the requesting provider Reduces the time to complete cost reports by providing a central repository for all claims data Provides an efficient means for flexible definition of business rules that allow changes to the business rules without changing core software 2 2 1 6 Logout The Logout hyperlink when selected logs the user out of the PS amp R System and displays the login page 2 2 2 Menu Bar The options available from the menu bar vary by user type The menu bar is located just below the PS amp R page s header area The types of users who can access the PS amp R System are e CMS Fiscal Intermediary Medicare Administrative Contractor Administrators e Fiscal Intermediary Medicare Administrative Contractors e Providers 2 2 3 Home When selected from the menu bar the Home menu option returns the user to the PS amp R System home page The contents of the menu bar changes depending on the type of user that is logged in The menu option available from the Home menu is User Preferences The following exhibit provides an example of the PS amp R System Home page when logged in as a provider user Refer to Chapter 3 Performing Tasks in the PS amp R for additional details about setting user
189. D E318 User Manual February 2009 Version No 2 0 Error Messages C 1 C 2 Provider Statistical and Reimbursement System Summary Report Request Select Provider s The Summary Report Request Select Provider s page error messages are presented in the following table Exhibit C27 Summary Report Request Select Provider s Page Error Messages Form Field User Type Validation Error Message ID By Provider CMS If no provider is selected from Error E025 No provider E025 Number FI MAC the By Provider Number list number s were chosen Non Admin box By Provider Type CMS If By Provider Number radio Error E024 Please select E024 Within Contractor button is not clicked this provider s Radio Button radio button must be clicked By Provider FI MAC If radio button is clicked at Error E026 By Provider E026 Type Radio Parent least one provider type must Type option selected but no Button Provider be selected provider type s chosen If By Provider Number radio Error E024 Please select E024 button or All Providers provider s Parent Provider users only is not clicked this radio button must be clicked By Provider CMS Provider type selected must Error E101 No providers of E101 Type Drop Down FI MAC apply to at least one provider the selected Provider Type s Menu Parent applicable to the FI PP are applicable Provider All Providers CMS Provide
190. D System Error PS amp R Period 1 From and To Dates Error E088 Period 1 From and To E088 must be entered for all dates are required for all selected providers Providers System Error PS amp R Empty Service Period is not Error E089 Empty Service Period E089 allowed between two not allowed between two populated Service Period populated Service Period System Error PS amp R Please enter valid date Error E090 Dates are not allowed E090 value s to be empty System Error PS amp R Exception occurred in the Error E135 Caught exception in E135 selectProviderParentByType selectProviderParentByType method amp arg1 System Error PS amp R No Providers are available Error E136 No providers are E136 available System Error PS amp R SDK Error Batch Job Creation Error E165 Error while trying to E165 Failed Build Batch Job amp arg1 Batch Job Creation Failed amp arg2 System Error PS amp R SDK Error Batch JobStep Error E166 Batch JobStep E166 Creation Failed Creation Failed for Job Step amp arg1 amp arg2 System Error PS amp R SDK Error Error in Building a Error E167 Error while trying to E167 Folder Build Folder amp arg1 amp arg2 System Error PS amp R SDK Error Error in Error E168 Error while trying to E168 Submitting a Job Submit Batch Job Build Parameter Creation Failed amp arg1 System Error PS amp R SDK Error Build Run Option Error E170 Build Run Option E170 failed failed for Job Step amp arg1 amp arg2
191. DD YYYY format E042 Paid Date To Date All Only numeric characters Error E042 Paid Date s entry contains a non numeric character or is not in MM DD YYYY format E042 Paid Date To Date All Entry must be in MM DD YYYY format Error E042 Paid Date s entry contains a non numeric character or is not in MM DD YYYY format E042 Paid Date To Date All Field must not be null Error E042 Paid Date s entry contains a non numeric character or is not in MM DD YYYY format E042 Select Paid From Date All Field must not be null Error E042 Paid From Date entry contains a non numeric character or is not in MM DD YYYY format E042 Select Paid From Date All Only numeric characters Error E042 Paid From Date entry contains a non numeric character or is not in MM DD YYYY format User Manual February 2009 Version No 2 0 C 35 Error Messages Provider Statistical and Reimbursement System ID E042 Form Field Select Paid From Date User Type All Validation Entry must be in MM DD YYYY format Error Message Error E042 Paid From Date entry contains a non numeric character or is not in MM DD YYYY format E042 Select Paid To Date All Field must not be null Error E042 Paid To Date entry contains a non numeric character or is not in MM DD YYYY format E042 Sele
192. DES SERVICES APPLIED FOR THE PERIODS 01 01 2004 12 31 2004 FULL EPISODES VISITS CHARGES VISITS CHARGES VISITS CHARGES VISITS CHARGES VISITS CHARGES VISITS CHARGES 0 55 0 38 2 15 0 111 100 62 6 875 00 0 00 4 875 00 250 00 725 00 69 12 12 894 74 100 62 6 875 00 0 00 4 875 00 250 00 LUPA EPISODES 0 0 00 0 0 0 00 0 0 0 00 0 0 0 00 0 0 0 00 0 o 0 00 0 0 0 0 0 00 0 0 00 0 00 0 00 0 00 o o o o ooo o 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 ooo o 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 PEP ONLY EPISODES SCIC ONLY EPISODES SCIC WITHIN A PEP 0 0 00 o 0 00 0 0 00 0 0 00 0 0 00 0 0 00 0 0 0 00 0 00 0 00 0 00 0 00 ooo o Page 1 Report 0044228 Report Type 339 TOTAL 55 0 39 2 55 38 2 User Manual February 2009 Version No 2 0 Outpatient Reports 5 40 100 62 6 875 00 0 00 4 875 00 250 00 725 00 69 12 12 89474 0 00 100 62 6 875 00 0 00 4 875 00 250 00 10 00 26 AM Provider Statistical and Reimbursement System Exhibit 5 21 Outpatient xxM xx9 Medicare Secondary Payer Lower Cost or Charge MSP LCC and Episodes Summary Report Template Second Page PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page 2 Paid Dates 01 01 04 THRU 10 01
193. Deduct 000 MS Coins 0 00 Cash Deduct 000 Cisim interest 0 00 Blood Decuct 000 Stndrd Ovrhd Amt 000 Coins 000 MSP 0 00 Net Reimb 0 00 Reimbursements Additional Information Gross Reimb 032 77 MSP Cash Deduct 000 LESS MSP Blood Deduct 0 00 MSP Coins 0 00 Cash Deduct 000 Cisim interest 0 00 Blood Deduct 000 Stndrd Ovrhd Amt 1 447 55 Coins 476 29 MSP 3020 Nat Rem gasae 10 37 23 AM User Manual February 2009 Version No 2 0 Outpatient Reports 5 52 Exhibit 5 30 Outpatient 831 ASC and ASC Fee Schedule After 12 90 Payment Reconciliation Detail Report First Page Provider Statistical and Reimbursement System Program ID REDESIGN Service Month End 11 30 99 Report Run Date 02 19 07 Provider FYE 09 30 Provider Number 100028 PARROTHEAD MEDICAL CENTER PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PAYMENT RECONCILIATION REPORT ASC AND ASC FEE SCHEDULE AFTER 12 90 Page 1 Report 044202 Report Type 831 Paid Dates 01 01 80 to 10 01 06 een iformaton Reimbusemans Additional information Paint Nene WOCOM Bill Freq 8 Gross Reimb 41755 MSP Cash Deduct 000 DCN 20289979184608 Trans Type c Rev HCPCS Charges MSP Blood Deduct 0 00 Part Cert a 057000000000 Processor ID 14000 Code Uns uss MSP Coins 0 00 Med Rerd 145000000000 i Cash Deduct 5000 Caim Interest 000 HIC Nume 186488514C1 9250 Blood Deduct 990 Stndrd Ovrhd A
194. ENTER Units Charges Gross Raimb Cash Deduct Bicod Deduct Coins mse Paye Red ponis TOTAL 3 000 200 000 020 000 000 2 00 0 09 Feb 7 2007 sika Pape 5 Report OD44202 Report Type 130 Paid Dates 01 01 00 to 10 01 06 Reimbursements Gross Reimb 000 LESS Cash Deduct 000 Blood Deduct 000 Coins 000 MSP 000 Psyc Red Nat Reimb 000 Reimbursements Gross Raimb 000 Less Cash Deduct 000 Blood Deduct 000 Coins 000 MSP 000 Psyc Red 000 Nat Reimb i200 Additional Information MSP Cash Deduct 000 MSP Blood Deduct 000 MSP Coins 000 Carn interest 000 Additional Information MSP Cash Deduct 000 MSP Blood Deduct 000 MSP Coins 000 Caim interest 000 12 33 54 PM The reports that are generated based on the outpatient xx0 All Other Cost Reimbursed report template are Inpatient Part B Cost Reimbursed 120 Outpatient Cost Reimbursed 130 e Outpatient Other All Other Cost Reimbursed 140 e SNF Inpatient Part B Cost Reimbursed 220 SNF Outpatient Cost Reimbursed 230 e Home Health Part B 340 Clinic Rural Health 710 Federally Qualified Health Center 730 Rehabilitation Facility 740 Comprehensive Outpatient Rehabilitation Facilities 750 Community Mental Health Center 760 Critical Access Hospital 850 User Manual February 2009 Version No 2 0 Outpatient Reports 5 37 Provider Statistical and Reim
195. Error PS amp R Logged in user has an invalid Error E329 PSR User does not E329 amp arg1 ID in his her profile have a valid amp arg1 ID Please call Help Desk C 17 Error Codes in Numeric Order The following table presents the error messages used throughout the PS amp R System in numeric order Exhibit C 17 Error Messages in Numeric Order ID Form Field User Type Validation Error Message Change Periods with All If multiple service period Error Service Periods Specific Dates Apply date ranges are provided overlap and or are not button service periods 2 3 and 4 s chronological From date entry must be greater than the previous service period s To Date note previous service period refers to any prior service period that has an entry this may require ignoring service periods without entries This validation assures chronological service periods and that there are no overlapping service periods Parent Provider is no Parent If you are requesting a Warning Service dates longer an owner of a Provider report from when a parent requested do not coincide child provider owned a child with requestor access provider it must be in the rights for Provider ID range of when the Provider These dates will be owned the child modified on the Confirm Report Request screen to reflect valid access dates Do you wish to Continue User Manual February 2009 V
196. Exhibit 2 1 Page Header CMS Provider Statistical amp Reimbursement System N Site Map Announcements FAQ Help Logout User ID PR100001 Monday June 11 SHANDS J ONVILLE MEDICAL CENTER 100001 User Manual System Overview and Common Features February 2009 Version No 1 2 2 Provider Statistical and Reimbursement System The following table provides a description of the fields in the page header Exhibit 2 2 Page Header Fields Field Site Map Announcements FAQ Help Logout User s Organization User ID gt Current Pages Date Definition Displays a visual structure of the pages within the PS amp R System to assist users to navigate within the PS amp R System Displays announcements pertaining to the type of user currently accessing the PS amp R System Displays answers to a list of frequently asked questions Launches the PS amp R System s online Help Online Help presents a list of common tasks you can perform while using the PS amp R System By clicking a task you can view detailed instructions for completing the task Logs the user out of the PS amp R System and displays the login page Displays the name of the user s organization If the user is a provider the provider organization name and number is displayed If the user is a Fiscal Intermediary Medicare Administrative Contractor the name of the Fiscal Intermediary Medicare Administrative Contractor organization
197. HARGES UNITS CHARGES UNITS CHARGES 0120 ROOM BOARD SEMI 0 0 00 0 0 00 607 142 593 00 0 0 00 TOTAL ACCOMMODATIONS o 0 00 o 0 00 07 142 593 00 9 0 00 ANCILLARY CHARGES REV CODE DESCRIPTION UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES 0250 PHARMACY o 000 0 0 00 37 16 096 17 0 0 00 0270 MED SUR SUPPLIES o 000 0 0 00 20 2 075 25 0 0 00 0300 LABORATORY or LAB o 000 0 0 00 2 118 35 o 0 00 0320 DX X RAY L 000 o 0 00 2 317 52 o 0 00 0420 PHYSICAL THERP o 000 0 0 00 687 22 175 00 LJ 0 00 0424 PHYS THERP EVAL 0 0 00 0 0 00 2 800 00 o 0 00 0430 OCCUPATION THER 0 000 0 50 00 s7 22 525 00 0 0 00 0434 OCCUP THERP EVAL o 000 0 0 00 23 725 00 0 0 00 0440 SPEECH PATHOL L 000 0 0 00 113 2 825 00 LJ 0 00 9444 SPEECH PATH EVAL o 000 o 0 00 10 250 00 LJ 0 00 TOTAL ANCILLARY L 0 00 0 0 00 2 049 68 307 29 L 0 00 TOTAL COVERED CHARGES 0 00 0 00 210 900 29 0 00 REIMBURSEMENT SECTION PAYMENT GROSS REIMBURSEMENT 0 00 0 00 222 971 29 0 00 CASH DEDUCTIBLE 0 00 0 00 0 00 0 00 Feb 5 2007 1 10 23 57 AM Note that report examples in this manual do not contain actual PS amp R data The data in the examples is fictional data User Manual February 2009 Version No 2 0 Performing Tasks in the PS amp R 3 30 Provider Statistical and Reimbursement System The following page appears if a detail report is selected from the Detail Report Inbox CATS Provider
198. Hospital Based OPPS 82P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the Hospice Hospital Based OPPS 82P report are included on the Medicare Cost Report 5 4 15 ASC and ASC Fee Schedule OPPS 83P The ASC and ASC Fee Schedule OPPS 83P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the ASC and ASC Fee Schedule OPPS 83P report are included on the Medicare Cost Report User Manual Outpatient Reports February 2009 Version No 2 0 5 21 Provider Statistical and Reimbursement System 5 5 xxZ Ambulance Blend Report Template The xxZ Outpatient Ambulance Blend Provider Summary report template displays summary statistic charge reimbursement and additional information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The data displayed in each section is determined by the report selected for generation The statistic
199. IP payments Ensure the amounts from reports 11A 18A 21A 118 and all other inpatient reports are transferred to the cost report 11S CLAIM INTEREST PAYMENTS Sum of interest paid on claims due to untimely claims processing Currently this field has no cost report usage 11S IRF PENALTY AMOUNT The 2596 penalty assessed for failure to submit IRF PAI data timely 11S LTCH SHORT STAY OUTLIER PAYMENTS The per diem payments made under PPS to the provider for a patient s stay in the facility prior to being transferred to another facility These payments are included in the net reimbursement field This field is shown for informational purposes only 11S CAP FED SPECIFIC 10096 Note This field equals the federal specific field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period This field should be used by hold harmless providers only 11S CAP OUTLIER 10096 Note This field equals the outlier field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period User Manual February 2009 Version No 2 0 Report Data B 20 Provider Statistical and Reimbursement System Report Type Data Element Description 11S DRG CMG WEIGHT This is the actual weight of the DRG CMG determined by
200. Information System HCRIS The types of cost reports are Hospital Cost Report CMS 2552 96 Skilled Nursing Facility Cost Report CMS 2540 96 Home Health Agency Cost Report CMS 1728 94 Renal Facility Cost Report CMS 265 94 and Hospice Cost Report CMS 1984 99 CPT Codes Current Procedural Terminology Codes The coding system for healthcare services developed by the CPT Editorial Panel of the American Medical Association AMA Critical Access Hospital CAH A healthcare facility that provides limited outpatient and inpatient hospital services to people in rural areas Crossover Claims Medicare claims that are covered by other insurance Medigap private business etc This term is usually reserved for Medicare Medicaid Deductible The amount that must be paid by a beneficiary before Medicare will pay for any items or services for that individual Department of Health and Human Services HHS Federal Government Department that is the parent of the Centers for Medicare and Medicaid Services Dialysis Center Renal A hospital unit that is approved to furnish the full spectrum of diagnostic therapeutic and rehabilitative services required for the care of the ESRD dialysis patients including inpatient dialysis furnished directly or under arrangement User Manual February 2009 Version No 2 0 Glossary D 2 Provider Statistical and Reimbursement System Term
201. Interest Payments for LUPA 329 PEP EPISODES WITHOUT OUTLIER This is Part B number of episodes without outlier for PEP 329 PEP HIPPS REIMBURSEMENT WITHOUT This is Part B HHPPS reimbursement without outlier for PEP OUTLIER 329 PEP EPISODES WITH OUTLIER This is Part B number of episodes with outlier for PEP 329 PEP HIPPS REIMBURSEMENT WITH This is Part B HHPPS reimbursement with outlier for PEP OUTLIER 329 PEP OUTLIER REIMBURSEMENTS This is Part B outlier reimbursement for PEP 329 PEP PROSTHETIC ORTHOTIC DEVICES This is Part B P amp O for PEP 329 PEP DME This is Part B DME for PEP 329 PEP OXYGEN This is Part B oxygen for PEP 329 PEP OTHER FEE REIMBURSEMENTS This is Part B other fee PEP 329 PEP GROSS REIMBURSEMENT Part B Gross Reimbursement for PEP 329 PEP DEDUCTIBLES This is Part B deductibles for PEP 329 PEP COINSURANCE This is Part B coinsurance for PEP 329 PEP NET MSP PAYMENTS This is Part B MSP recon for PEP 329 PEP MSP RECONCILIATION This is Part B net MSP payment for PEP 329 PEP OTHER ADJ USTMENTS This is Part B other adjustments for PEP User Manual February 2009 Version No 2 0 Report Data B 113 Provider Statistical and Reimbursement System Report Type Data Element Description 329 PEP NET REIMBURSEMENT This is Part B net reimbursement for PEP 329 PEP CLAIM INTEREST PAYMENTS Part B Claim Intere
202. LIP The DSH LIP amount value code 18 shown on the PS amp R report represents interim payments calculated by the PPS Pricer program For cost reporting purposes the DSH LIP amount must be recomputed for qualifying hospitals 11U IME TEACHING ADJ Indirect medical education Teaching adjustment Value Code 19 amount shown on the PS amp R are estimated payments made on a bill by bill basis by the PPS Pricer program For cost reporting purposes the amount must be recomputed 11U NEW TECHNOLOGY Summarizes new technology payments Value code 77 made under the Prospective Payment System 11U IPF ECT Summarizes IPF ECT Inpatient Psych Facility Electro Convulsive Therapy payments made under the Prospective Payment System 11U TOTAL OPERATING PAYMENTS This is the sum of the operating amounts for HSP FSP outlier DSH LI P IME teaching adjustment new technology IPF ECT and exception payments 11U HOSPITAL SPECIFIC This is the hospital specific portion of the PPS payment for capital The field will be zero for providers paid based on the hold harmless old capital or the hold harmless 100 percent federal method and for new hospitals during their first two years of operation 11U FEDERAL SPECIFIC This field includes the federal portion of the PPS payment for capital This field will also include the new capital amount for hospitals paid under the hold harmless old capital method 11U
203. List Box 11x 12x 13x 14x 72x The example in the previous exhibit displays a list box containing report types A list box contains a list of items in alphabetical or numerical order that are available from which the user chooses The user can select one or multiple items An item is considered selected when the item is highlighted To highlight a single item the user clicks the name of the item To highlight multiple items the user can scroll through the list and use Window s standard Ctrl click to select non continuous items or shift click to select continuous items The user can remove the highlight from any highlighted item by clicking a different item Any item that is highlighted in the list box is considered a selected item 2 3 5 Transfer List Boxes Transfer list boxes enable a user to choose one item or multiple items from an available items list box and transfer the items to another selected items list box The exhibit below provides an example of a transfer list box User Manual System Overview and Common Features February 2009 Version No 1 2 11 Provider Statistical and Reimbursement System Exhibit 2 13 Transfer List Box Text Box 1 Search Search m List Box 2 1 Selected Items ist Box 1 ss Available Items 14x 72x zi The exhibit displays an example of a generic transfer list box In this example three labels have been added for
204. M DD YYYY format Mailed Date is FI MAC Mailed Date must be in Error E042 Mailed Date E042 not in Admin MM DD YYYY format contains a non numeric MM DD YYYY character or is not in format MM DD YYYY format Mailed Date FI MAC Mailed Date must be an Error E001 Mailed Date E001 contains an Admin existing calendar day contains an invalid month invalid month day and or year day and or year Mailed Date has FI MAC Mailed Date was successfully The Mailed Date has been S001 been successfully Admin updated by the user successfully updated updated User Manual February 2009 Version No 2 0 Error Messages C 19 C 13 Provider Statistical and Reimbursement System Miscellaneous Report Request Select Reports The Miscellaneous Report Request Select Reports page error messages are presented in the following table Exhibit C 13 Miscellaneous Report Request Select Reports Page Error Messages Form Field User Type Validation Error Message ID Invalid Report CMS If the Certified Load Reports Error E317 No reports were E317 Types Radio FI MAC radio button is not selected selected Button Admin this must be selected Certified Load CMS If the Invalid Report Types Error E317 No reports were E317 Control Report FI MAC or the Claim Load Control selected Radio Button Admin Report radio button is not selected this must be sel
205. NERAL HOSPITAL Reimbursements Additional Info yp Units Charges GAPC Cash Deduct Blood Deduct Coles MS MSP Recon Psyc Red Lise item Reimb Elected Coins GAPC 8 14457 MSP Cash Deduct 0 00 TOTAL 39 3436963 8 4457 100 00 000 1823 57 0200 000 000 5621500 202 PLUS MSP Stood Deduct 0 00 MSP Coiss 026 Outlier 52052 Claim interest 0 00 Gross Reimb 8165 05 Elected Coins 0 00 LESS Cash Deduct 102 09 Blood Deduct 202 Coins 182357 MSP Ko MSP Recon 2 00 Other Adis yx Poyc Red 2 00 Net Reimb 5623552 Feb 7 2007 5 12 18 25 PM The reports that are generated based on the outpatient xxP Outpatient Prospective Payment System OPPS report template are e Inpatient Part B OPPS 12P e Outpatient OPPS 13P e Outpatient Other OPPS 14P e SNF Outpatient OPPS 22P e SNF Outpatient OPPS 23P e SNF Outpatient OPPS 24P e Home Health Outpatient OPPS not HHPPS 34P Clinic Rural Health OPPS 71P e Federally Qualified Health Center OPPS 73P e Rehabilitation Facility OPPS 74P User Manual Outpatient Reports February 2009 Version No 2 0 5 19 Provider Statistical and Reimbursement System e Comprehensive Outpatient Rehabilitation Facilities OPPS 75P e Community Mental Health Center OPPS 76P e Hospice Non Hospital Based OPPS 81P Hospice Hospital Based OPPS 82P e ASC and ASC Fee Schedule OPPS 83P A brief description of
206. Numbers and local contractor assigned provider numbers The goal is to give providers one uniform number to use for all government health care programs Each 10 digit NPI belongs to the designated provider for life regardless of location or specialty changes Nursing Facility A facility which primarily provides to residents skilled nursing care and relate services for the rehabilitation of injured disabled or sick persons or on a regular basis health related care services above the level of custodial care to other than mentally retarded individuals Nursing Home A residence that provides a room meals and help with activities of daily living and recreation Generally nursing home residents have physical or mental problems that keep them from living on their own usually requiring daily assistance OPPS Outpatient Prospective Payment System Outlier Additions to a full episode payment in cases where costs of services delivered are estimated to exceed a fixed loss threshold HH PPS outliers are computed as part of Medicare claims payment by Pricer Software Outpatient A patient who receives care at a hospital or other health facility without being admitted to the facility Outpatient care also refers to care given in organized programs such as outpatient clinics Outpatient Care Medical or surgical care that does not include an overnight hospital stay Outpatient Hospital A portion of a hospital that pro
207. ODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 720 ESRD COND CODE The condition code tells the type of treatment furnished 720 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 720 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 720 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 720 CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 720 COINSURANCE The actual coinsurance amount from the paid claim record 720 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 720 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 720 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 725 CLAIMS Currently this field has no cost report
208. OGY Summarizes new technology payments Value code 77 made under the Prospective Payment System 11V IPF ECT Summarizes IPF ECT Inpatient Psych Facility Electro Convulsive Therapy payments made under the Prospective Payment System 11V TOTAL OPERATING PAYMENTS This is the sum of the operating amounts for HSP FSP outlier DSH LI P IME teaching adjustment new technology IPF ECT and exception payments 11V HOSPITAL SPECIFIC This is the hospital specific portion of the PPS payment for capital The field will be zero for providers paid based on the hold harmless old capital or the hold harmless 100 percent federal method and for new hospitals during their first two years of operation 11V FEDERAL SPECIFIC This field includes the federal portion of the PPS payment for capital This field will also include the new capital amount for hospitals paid under the hold harmless old capital method 11V OUTLIER This field will show the outlier portion of the PPS payment for capital 11V HOLD HARMLESS This field shows the hold harmless amount paid for old capital based on the hold harmless old capital method 11V DSH This is the disproportionate share portion of the PPS capital payment 11V INDIRECT MEDI CAL EDUCATION This is the indirect medical education adjustment payment to PPS teaching hospitals applicable to PPS capital payments 11V EXCEPTI ONS This is t
209. OM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 22A DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 22A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 22A GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 22A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 22A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 22A COI NSURANCE The actual coinsurance amount from the paid claim record 22A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 22A NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 22A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 23A CLAIMS Currently this field has no cost report usage 23A UNITS The number of units applicable to each revenu
210. ONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 71P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 71P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 52 Provider Statistical and Reimbursement System Report Type Data Element Description 71P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 71P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 73P CLAI MS Currently this field has no cost report usage 73P UNITS The number of units applicable to each revenue code 73P CHARGES The charges applicable to each revenue code 73P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes
211. OSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 14P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 14P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 14P COINSURANCE The actual coinsurance amount from the paid claim record 14P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 14P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 14P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 14P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 47 Provider Statistical and Reimbursement System Report Type Data Element Description 14P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the
212. Outpatient Vaccine Part B 100 Reasonable Cost 232 Home Health Vaccine Part B 10096 Reasonable Cost 342 Clinic Rural Health Vaccine Part B 10096 Reasonable Cost 712 Federally Qualified Health Center Vaccine Part B 10096 Reasonable Cost 732 Rehabilitation Facility Vaccine Part B 10096 Reasonable Cost 742 Comprehensive Outpatient Rehabilitation Facilities Vaccine Part B 100 Reasonable Cost 752 Community Mental Health Center Vaccine Part B 10096 Reasonable Cost 762 ASC and ASC Fee Schedule Vaccine Part B 10096 Reasonable Cost 832 Critical Access Hospital Vaccines Part B 10096 Reasonable Cost 852 xx5 Fee Reimbursed Report Template Inpatient Part B Fee Reimbursed 125 Outpatient Fee Reimbursed 135 Outpatient Other Fee Reimbursed 145 SNF Inpatient Fee Reimbursed 225 SNF Outpatient Fee Reimbursed 235 Home Health Part B Fee Reimbursed 345 Federally Qualified Health Center Fee Reimbursed 735 Rehabilitation Facility Fee Reimbursed 745 Comprehensive Outpatient Rehabilitation Facilities Fee Reimbursed 755 Community Mental Health Center Fee Reimbursed 765 ASC and ASC Fee Schedule Fee Reimbursed 835 Critical Access Hospital Fee Reimbursed 855 e xx0 All Other Cost Reimbursed Report Template Inpatient Part B Cost Reimbursed 120 Outpatient Cost Reimbursed 130 Outpatient Other All Othe
213. P BASED OR INDEPEND RENAL DIALYSIS CENTER COMPOSITE RATE SERVICES Report OD44203 Report Type 720 SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 04 03 31 04 04 01 04 06 30 04 No Data Requested No Data Requested 18 38 UNITS cov ANG PYMT UNITS Cov ANG PYMT UNITS cov AVG PYMT UNITS cov ANG PYMT CHG PYMTS RATE CHG PYMTS RATE CHG PYMTS RATE CHG PYMTS RATE 20 2 523 80 126 19 233 29 402 27 126 19 0 00 0 00 0 0 00 0 00 10 1 261 90 126 19 0 00 0 00 n 1 520 08 138 19 0 000 0 00 0 00 0 00 43 2 325 44 54 08 126 6 81408 54 06 0 00 0 00 0 0 00 0 00 3 43857 145 19 0 00 0 00 0 0 00 0 00 51 2 758 08 54 06 0 00 0 00 74 6 369 33 86 07 423 S4O 67490 9616 0 00 0 00 6 369 33 40 674 30 0 00 0 00 1 273 90 8 13495 0 00 0 00 160 80 2465 5 070 78 32 379 15 f 50 00 0 00 71 FULL CARE IN UNIT 72 SELF CARE IN UNIT 73 SELF CARE TRAINING 74 HOME METHOD 1 76 BACK UP IN FACILITY DIALYSIS Feb 2 2007 1 7 54 02 AM User Manual February 2009 Version No 2 0 Outpatient Reports 5 8 Provider Statistical and Reimbursement System Exhibit 5 2 Outpatient 72x Payment Reconciliation Detail Report Template PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page Service Month End 01 31 04 HOSP BASED OR INDEPEND RENAL DIALYSIS CENTER COMPOSITE RATE SERVICES Report OD42202
214. P 0274 Displays by itself Part B prosthetics and orthotics charges with outlier 399 PEP 029X All revenue codes lines Part B durable medical equipment charges with outlier where the first three positions 029 are rolled up 399 PEP 042X All revenue code lines Total physical therapy covered charges during PEP episode where the first three positions 042 are rolled up 399 PEP 043X All revenue code lines Total occupational therapy covered charges during PEP where the first three positions 043 episode are rolled up 399 PEP 044X All revenue code lines Total speech therapy covered charges during PEP episode where the first three positions 044 are rolled up 399 PEP 055X All revenue code lines Total covered charges related to nursing services during PEP where the first three positions 055 episode are rolled up 399 PEP 056X All revenue code lines Total covered charges related to med soc serv during PEP where the first three positions 056 are rolled up episode User Manual February 2009 Version No 2 0 Report Data B 149 Provider Statistical and Reimbursement System Report Type Data Element Description 399 PEP 057X All revenue code lines Total covered charges related to home health aide serv during where the first three positions 057 PEP episode are rolled up 399 PEP 058X All revenue code lines Part B other visit
215. P PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 820 MSP RECONCILIATI ON This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 820 OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports User Manual February 2009 Version No 2 0 Report Data B 92 Provider Statistical and Reimbursement System Report Type Data Element Description 820 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 820 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 82A MEDICARE DAYS Currently this field has no cost report usage 82A CLAIMS Currently this field has no cost report usage 82A TOTAL UNDUPLICATED CENSUS The unduplicated census count of the hospice for all patients COUNT initially admitted and filing an election within the reporti
216. PCS and charges for each revenue code The reimbursements section shows how Net Reimbursement is calculated The additional information section contains data such as deductibles HIPPS code HIPPS weight and payment type A monthly totals section is displayed at the bottom of the report which sums the information from the sections above User Manual Outpatient Reports February 2009 Version No 2 0 5 39 Provider Statistical and Reimbursement System Exhibit 5 20 Outpatient xxM xx9 Medicare Secondary Payer Lower Cost or Charge MSP LCC and Episodes Summary Report Template First Page Program ID REDESIGN Paid Dates 01 01 04 THRU 10 01 06 Report Run Date 02 05 07 Provider FYE 12 31 Provider Number 137008 MOBILE NURSE SERVICES CHARGE SECTION SERVICES WITHOUT OUTLIER REV CODE DESCRIPTION 027X MEDICAL SURGICAL SUPPLIES AND DEVICES 042X PHYSICAL THERAPY 043X OCCUPATIONAL THERAPY 055X SKILLED NURSING 056X MEDICAL SOCIAL SERVICES 057X HOME HEALTH AIDE 0623 SURGICAL DRESSINGS TOT SERVICES WITHOUT OUTLIER SERVICES WITH OUTLIER REV CODE DESCRIPTION TOT SERVICES WITH OUTLIER TOTAL SERVICES REV CODE DESCRIPTION 027X MEDICAL SURGICAL SUPPLIES AND DEVICES 042X PHYSICAL THERAPY 043X OCCUPATIONAL THERAPY 055X SKILLED NURSING 056X MEDICAL SOCIAL SERVICES Feb 5 2007 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PROVIDER SUMMARY REPORT HOME HEALTH PPS PART A EPISO
217. PIP 0 00 0 00 0 00 ACTUAL CLAIM PAYMENTS FOR PIP 0 00 0 00 0 00 CLAIM INTEREST PAYMENTS 0 00 0 00 0 00 IRF PENALTY AMOUNT 0 00 0 00 0 00 LTCH SHORT STAY OUTLIER PAYMENTS 0 00 0 00 0 00 CAP FED SPEOFIC 100 0 00 314 69 0 00 CAP OUTLIER 100 0 00 0 00 0 00 DISCHARGES 0 2 0 DRG CMG WEIGHT 0 0000 0 0000 0 0000 WEIGHT DISCHARGES 0 0000 0 0000 0 0000 DISCHARGE FRACTION 0 0 0 DRG WEIGHT FRACTION 0 0000 0 0000 0 0000 DRG WEIGHT FRACTION DISCHARGES 0 0000 0 0000 0 0000 Sep 22 2008 zu 000 000 0 00 000 000 0 00 000 0 0000 0 0000 0 0000 0 0000 1 29 49 PM User Manual February 2009 Version No 2 0 Inpatient Reports 4 8 Provider Statistical and Reimbursement System Exhibit 4 7 Inpatient 11x Payment Reconciliation Detail Report Template First Page PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Service Month End 03 31 04 INPATIENT PART A MSP LCC Report Run Date 02 07 07 Provider FYE 12 31 Provider Number 700007 PETERBORO GENERAL HOSPITAL Patak Nan FALOS BN Freq 1 Raw Code Units Charges Operating Capital Payment DCN 20448788450204 Trans Type 0200 1 5178600 Pent Cagri a 130000020009 Dschrg Patnt Ce cs o 8747 SP 9000 HSP 000 Gross Reimb Med Rerd a 29300000000 Dsc rg Patnt Stat Yes 0252 6 516523 gt 9624907 FS 956250 Les HIC Num 48157042A DRG CMG Cd NG mi o 3223 Outlier
218. PITAL for service month end 3 31 04 Operating Capital Payment Uus Charges Hsr 200 HSP 020 Gross Reimb Med Days 2 Discharge Count 2 TOTAL 2 392756 FS SHANT FFP 1306828 ge Outiier 200 Ostir s020 DSH UP 736 45 Hold Harm 020 Cash Dedect IME Teach Adj 262 03 OSH 4774 Blood Deduct New Tech yo IME 73 Coins mm Be emo gg Total 1241619 Total pna a minia m Jar Adis Net Reim Feb 7 2007 1 514 35 000 wo 000 5853 03 000 2045 55 25000 13 586 33 876 00 sao 205 5757625 200 4378 37 75571 Page 1 Report OD24202 Report Type 11A Paid Dates 01 01 04 to 10 01 06 Additional information MSP Cash Deduct 0 00 MSP Blood Deduct 0 00 MSP Coles 000 Calc Raimb PIP 000 Actual Cim Pymets PIP Claim interest seco IRF Penalty 0 00 LTO Short Stay Outtr 0 00 Cap Pay Cor Li Cap FSP 100 55250 Cap Outr 100 000 DRG CMG Wet Dschrg Frctn ORG Wet Freta MSP Cash Deduct 0 00 MSP Sood Deduct 0 00 MSP Coles 000 Calc Reimb PIP 0 00 Actual Cim Pymets PiP Claim Interest 000 IRF Penalty 0 00 LTCH Short Stay Outir 0 00 Cap Pay C Li Cap FSP 100 40 19 Cap Outr e 100 000 DRG CMG Wer Dschrg Fretn ORG Wet Freta Additional information MSP Cash Deduct 0 00 MSP Sood Deduct 0 00 MSP Coins 0 00 Calc Reimb PIP 0 20 Actual Cim Pymats PIP Chaim interest 0 00 IRF Penalty 020 LTO Short Stay Outtr 0 00 Cap F
219. PPS Interim Bills 11V User Manual Inpatient Reports February 2009 Version No 2 0 4 10 Provider Statistical and Reimbursement System e Religious Non Medical Inpatient Part A 410 The report that is generated based on the Inpatient 115 report template is e Inpatient Fee Reimbursed 115 A brief description of these reports is provided in the following sections The reports are presented in the order in which the Paid Claims file is processed 4 2 1 Inpatient Fee Reimbursed 115 The Inpatient Fee Reimbursed 115 report shows covered charges and reimbursement for fee reimbursed services for inpatient services The detail report shows reimbursement by revenue code for inpatient services The items reported on the Inpatient Fee Reimbursed 115 report are not to be included on the Medicare Cost Report The Inpatient Long Term Care Part A 115 report is generated automatically if the Inpatient Part A 110 report is requested Although the Inpatient Fee Reimbursed 115 report data processing is performed with the 11x reports the summary and detail reports have their own format The following exhibits provide examples of the Inpatient 115 Provider Summary report and the Inpatient 115 Payment Reconciliation detail report Exhibit 4 9 Inpatient 115 Provider Summary Report Layout PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page 1 Paid Dates 02 01 04 THRU 10
220. Part B HIPPS reimbursement without outlier for full episodes WITHOUT OUTLIER 399 FULL EPISODES WITH OUTLIER Part B number of episodes with outlier for full episodes 399 FULL HIPPS REIMBURSEMENT WITH Part B HI PPS reimbursement with outlier for full episodes OUTLIER 399 FULL OUTLIER REI MBURSEMENTS Part B outlier reimbursement for full episodes 399 FULL PROSTHETI C ORTHOTIC Total prosthetics and orthotics for full episodes DEVICES 399 FULL DME Total durable medical equipment for full episodes 399 FULL OXYGEN Oxygen for full episodes 399 FULL OTHER FEE REIMBURSEMENTS Total other fee reimbursement 399 FULL GROSS REIMBURSEMENT Part B gross reimbursement for full episodes 399 FULL DEDUCTIBLES Total Part B deductibles 399 FULL COINSURANCE Total coinsurance 399 FULL NET MSP PAYMENTS Total MSP 399 FULL MSP RECONCILIATION Net MSP for Part B 399 FULL OTHER ADJUSTMENTS Total other adjustment 399 FULL NET REIMBURSEMENT Total net reimbursement 399 FULL CLAIM INTEREST PAYMENTS Part B claim interest payments for full episodes 399 LUPA EPISODES WITHOUT OUTLIER Part B of Episodes w o outlier for LUPA User Manual February 2009 Version No 2 0 Report Data B 159 Provider Statistical and Reimbursement System Report Type Data Element Description 399 LUPA HIPPS REIMBURSEMENT Part B HI PPS reimbursement without
221. Radio Button Parent radio button or AII provider s Provider Providers Parent Provider users only is not clicked this radio button must be clicked E025 By Provider Number CMS FI MAC If no provider is selected Error E025 No provider Non Admin from the By Provider number s were chosen Number list box E025 By Provider Number CMS FI MAC If radio button is clicked at Error E025 No provider Radio Button Parent least one provider number number s were chosen Provider must be selected E025 List Box 2 Selected CMS FI MAC Must contain at least one Error E025 No provider Items Provider provider number s were chosen E026 By Provider Type FI MAC If radio button is clicked at Error E026 By Provider Radio Button Parent least one provider type must Type option selected Provider be selected but no provider type s chosen User Manual February 2009 Version No 2 0 Error Messages C 32 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message E027 By Provider Type CMS If radio button is clicked at Error E027 If the By Within Contractor least one provider type and Provider Type Within Radio Button one contractor must be Contractor option is selected selected at least one provider type and one contractor must be selected E034 By Report Group All If By Service Type radio Error E034 No reports Radio
222. Reimbursed Claim lines that do not satisfy requirements for presentation on xx2 reports are presented on the xx5 Fee Reimbursed report template if the claim line has a HCPCS Code and the Total Fee Schedule Amount is greater than zero 0 User Manual Outpatient Reports February 2009 Version No 2 0 5 5 Provider Statistical and Reimbursement System 5 1 7 Package Services Assignment Package services claim lines claim lines with an APC Service Indicator of N or APC Package flag of 1 or 2 are assigned as follows e If any claim line goes to the xxP Outpatient Prospective Payment System template the Package s goes to the xxP Outpatient Prospective Payment System report template e If any claim line goes to the xx5 Fee Reimbursed template the Package s goes to the xx5 Fee Reimbursed report template e If any claim line goes to the xxZ Ambulance Blend template the Package s goes to the xxZ Ambulance Blend report template e If the claim line s bill type is 83x any unassigned packages go to the 831 ASC and ASC Fee Schedule After 12 90 report e Any unassigned Package lines go to the xx0 All Other report template 5 1 8 831 ASC and ASC Fee Schedule After 12 90 Claim lines with a type of bill of 83x that do not satisfy requirements for presentation on any of the previously processed report templates are presented on the 831 ASC and ASC Fee Schedule After 12 90 831 report 5 1 9 xxO All Other
223. Report Run Date 02 07 07 Report Type 720 Provider FYE 12 31 E d Paid Dates 01 01 04 to 10 01 06 Provider Number 702581 INDIAN BEACH DIALYSIS CENTER EE Patet Nox SNELR Bill Freq Gross Reimb 1389 MS Cash Deduct 0 00 p z Rev CovChg Cam ESRO R ct Line Item z DCN 20408948370304 Trans Type Code HCPCS Un ee Deduce OS MP pa Pants Reimb us MS Coins sece Pent Carl a 000000000 Processor ID 14000 Claim interest soco Med Rend amp ESRD Condition Code 73 0081 M0906 n 919 009 2764 O OSO 190 05 Cash Detect 000 Claim Report Spits no HIC Num 55235686004 Weight Kg TOTA 13819 000 2766 0 0 s snog Coins 2764 Recpt Dt 04 12 04 Height m aao a i MSP 0 00 Paid Ot 04 2 04 Birth Ot 1112 58 ESRD Recta Ntwk Pymts 050 Service From 01 29 04 Net Reimb 1005 Service Thru 01 29 04 Monthly Totals for INDIAN BEACH DIALYSIS CENTER for service month end 1 31 04 Reimbursements Additional Information CowC Cam ESRORdcn Liweitem Gros Reimb 138 9 MSP Cash Dedect soco UMS qms deduct CS M pwo Pants Ried um MS Coins soco TOTAL 1 138 19 000 2764 000 soso 110 05 Claim interest soco Cash Deduct 000 Coins 27 64 MSP 000 ESRD Recta Ntek Pymts 050 Net Reimb 110 05 CONDITION CODE KEY 71 FULL CARE IN UNIT 72 SELF CARE IN UNIT 73 SELF CARE TRAINING 74 HOME METHOD 1 76 BACK UP IN FACILITY DIALYSIS Feb 7 2007 1 2 34 57 PM The reports that are generated
224. Reports February 2009 Version No 2 0 4 1 Provider Statistical and Reimbursement System Exhibit 4 2 Inpatient Report Header Fields Field Definition Program ID The release number of the PS amp R System in effect when the report was generated Paid Dates The range of paid dates for which the report contains data Service Month End Date Report Run Date Provider FYE Provider Number Report Name Page lt gt Report Report Type This field only appears on inpatient and outpatient detail reports The ending month of service for the current page of the report The date the report was generated in the PS amp RSystem The provider s fiscal year end for which the report was generated The provider number and corresponding name for which the report was generated The name of the report that was generated The sequential page number of the report page The identification number assigned to the report The three or four character identifier indicating the type of report that was generated The report footer displays the date the report was generated the sequential page number of the report and the time the report was generated The following exhibit provides an example of the report footer Exhibit 4 3 Inpatient Report Footer Feb 5 2007 10 23 57 AM This chapter provides a description of each inpatient report template and provides a summary of the reports generated using each template Chapter 5 Outpatien
225. Request a report using a favorite request e View requested reports in the Report Inbox e Change the default contractor ID accessed when logging in to the Provider Statistical and Reimbursement System User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 3 Provider Statistical and Reimbursement System 3 1 User Preferences To change the settings for default pages that display when you access the PS amp R System select the User Preferences option from the Home menu The following page appears You can change the default contractor ID with which to work or specify the default Report Inbox page and the default Request Report page to display when you select the Report Inbox or Request Report menus in the PS amp R System Select the radio button corresponding to the desired default pages to access when working in the PS amp R System Click Save to save your preferred pages to access in the PS amp R System Provider Statistical amp Reimbursement System Sita MapislAonauncements MAC 14000 User Preferences Home Report Inbox Request Report User Preferences User Preferences 1 Set User Preferences Set Contractor ID Change Contractor ID Set Default Pages Default Report Inbox Page Summary Report Inbox C Detail Report Inbox Default Request Report Page Favorite Requests C Request Summary C Request Detail The following section provides the instructions to change the default contract
226. S Other adjustments for Part B 339 FULL NET REIMBURSEMENT Net reimbursement for Part B 339 FULL CLAIM INTEREST PAYMENTS This is the Part A information 339 LUPA EPISODES WITHOUT OUTLIER This is the Part A information 339 LUPA HIPPS REIMBURSEMENT This is the Part A information WITHOUT OUTLIER 339 LUPA EPISODES WITH OUTLIER This is the Part A information 339 LUPA HIPPS REIMBURSEMENT WITH This is the Part A information OUTLIER 339 LUPA OUTLIER REIMBURSEMENTS This is the Part A information 339 LUPA PROSTHETIC ORTHOTIC This is the Part A information DEVICES 339 LUPA DME This is the Part A information 339 LUPA OXYGEN This is the Part A information 339 LUPA OTHER FEE REIMBURSEMENTS This is the Part A information 339 LUPA GROSS REIMBURSEMENT This is the Part A information 339 LUPA DEDUCTIBLES This is the Part A information 339 LUPA COINSURANCE This is the Part A information 339 LUPA NET MSP PAYMENTS This is the Part A information 339 LUPA MSP RECONCILIATION This is the Part A information 339 LUPA OTHER ADJ USTMENTS This is the Part A information 339 LUPA NET REIMBURSEMENT This is the Part A information 339 LUPA CLAIM INTEREST PAYMENTS This is the Part A information 339 PEP EPISODES WITHOUT OUTLIER This is the Part A information 339 PEP HIPPS REIMBURSEMENT WITHOUT This is the Part A information OUTLIER 339 PEP EPISODES WITH OUTLIER This is the Part A information 339 PEP HIPPS REIMBURSEMENT WITH This is t
227. SITS This is the Part B MSP LCC information 33M CHARGES This is the Part B MSP LCC information 33M REV CODE This is the Part B MSP LCC information 33M DESCRIPTION This is the Part B MSP LCC information 33M TOT SERVICES WITHOUT OUTLIER This is the Part B MSP LCC information 33M TOT SERVICES WITH OUTLIER This is the Part B MSP LCC information 33M TOT COVERED SERVICES This is the Part B MSP LCC information 33M EPISODES WITHOUT OUTLIER This is the Part B MSP LCC information 33M HIPPS REIMBURSEMENT WITHOUT This is the Part B MSP LCC information OUTLIER 33M EPISODES WITH OUTLIER This is the Part B MSP LCC information 33M HIPPS REIMBURSEMENT WITH This is the Part B MSP LCC information OUTLIER 33M OUTLIER REI MBURSEMENTS This is the Part B MSP LCC information 33M PROSTHETIC ORTHOTIC DEVI CES This is the Part B MSP LCC information 33M DME This is the Part B MSP LCC information 33M OXYGEN This is the Part B MSP LCC information 33M OTHER FEE REIMBURSEMENTS This is the Part B MSP LCC information 33M GROSS REI MBURSEMENT This is the Part B MSP LCC information 33M DEDUCTIBLES This is the Part B MSP LCC information 33M COINSURANCE This is the Part B MSP LCC information 33M NET MSP PAYMENTS This is the Part B MSP LCC information 33M MSP RECONCILIATION This is the Part B MSP LCC information 33M OTHER ADJUSTMENTS This is the Part B MSP LCC information 33M NET REIMBURSEMENT This is the Part B MSP LCC information 33M CLAIM INTEREST PAYMENTS T
228. SNF Inpatient Part B Cost Reimbursed 220 report are included on the Medicare Cost Report 5 8 5 SNF Outpatient Cost Reimbursed 230 The SNF Outpatient Cost Reimbursed 230 report summarizes skilled nursing facility outpatient services The items reported on the SNF Outpatient Cost Reimbursed 230 report are included on the Medicare Cost Report 5 8 6 Home Health Part B 340 The Home Health Part B 340 report summarizes home health agency outpatient services The items reported on the Home Health Part B 340 report are included on the Medicare Cost Report 5 8 7 Clinic Rural Health 710 The Clinic Rural Health 710 report summarizes data for rural health clinic services bill type 71x paid based on an all inclusive rate The items reported on the Clinic Rural Health 710 report are included on the Medicare Cost Report 5 8 8 Federally Qualified Health Center 730 The Federally Qualified Health Center 730 report summarizes data for Federally Qualified Health Clinic services bill type 73x paid based on an all inclusive rate The items reported on the Federally Qualified Health Center 730 report are included on the Medicare Cost Report 5 8 9 Rehabilitation Facility 740 The Rehabilitation Facility 740 report shows cost reimbursed data if any by accommodation and ancillary service revenue codes This report captures lines of claims paid under the cost reimbursed method for Outpatient Rehab
229. SP 100k 1 105 09 Cap Outr 100 5020 DRG CMG Wgt Wguoschrgs Dschrg Frctn DRG Wet Freta DRG Wet FretevDschrgs 123454 PM User Manual February 2009 Version No 2 0 Inpatient Reports 4 9 Provider Statistical and Reimbursement System Exhibit 4 8 Inpatient 11x Payment Reconciliation Detail Report Template Last Page PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page 2 Service Month End N A INPATIENT PART A MSP LCC Report OD44202 Report Run Date 02 07 07 Report Type 11A Provider FYE 12 21 Paid Dates 01 01 04 to 10 01 06 Provider Number T00007 PETERBORO GENERAL HOSPITAL Service Period and Report Type Totals Service Period Reimbursements Additional information 01 01 2004 01 01 2006 Units Charges Operating Capital Payment MS Cast Dodect 020 Med Days 2 Discharge Count 2 TOTAL 2 9920796 MS Blood Deduct 0 20 HS S000 ns 000 Gross Reimb 13 586 33 MS Coins 30 00 FSP 1417 70 FSP 110828 ess Cak Reimb PIP 0 00 Outier 000 Outr 0 00 Actual Cim Pymnts PIP DSH UP 73645 Hold Harm 000 Cam Deduct 876 00 Caim interest 0 00 IME Teach Adj 26203 DSH 4774 Blood Deduct 0 00 IRF Penalty 0 00 New Tech 0 00 IME 1732 Coins S000 LTCH Short Stay Ostir s020 IPF ECT S000 Excptes 000 MSP 5757525 Cap FSP 8 100 1 105 09 o Tt siias MSP Pass Thru Recon s000 Cap Ostir 100 0 00 Ta AM oce 1
230. Statistical amp Reimbursement System Site Map Announcements 725000 ser ID TRTES t Inbox Thursday Augu Home Report Inbox Request Report Detail Report Inbox Detail Report Inbox Request Name TRTEST17 D HALF PIPE Provider Number Report s File Size T00006 110 115 118 119 114 384 KB TO0006 120 125 12P 130 132 135 13P 13Z 235 KB To open the report click the provider number and report type hyperlink corresponding to the desired report or click Back to return to the previous page An example of the detail report cover page follows PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM REPORT COVER PAGE FOR PROVIDER T00007 Report Type Total of Pages Report Type Total of Pages Report Type Total of Pages Report Type Total of Pages 110 13 115 1 118 1 11A 1 122 7 125 1 12P 1 User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 31 Provider Statistical and Reimbursement System An example of detail report in PDF format follows PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program PAYMENT RECONCILIATION REPORT Page Service Mont End 01 31 04 OUTPATIENT COST REIMBURSED Report amp CO4QUZ Report Ren Date 01 30 07 Report Type 130 Provider FYE 12 31 Paid Dates 01 01 03 to 10 01 06 15650 soo 3009 pro aw 008 palng Pen TOTAL 4 959 5050 jum es Stom je dapes Raed Deauct 200 Caim Rapor
231. Summary Report Request Select Report s sssssssss nne C 3 C 4 Summary Report Request Select Service Period s eseseeeeeeeeee C 4 User Manual Table of Contents February 2009 Version No 2 0 vi Provider Statistical and Reimbursement System C 5 Summary Report Request Select Report Format 2 asaasasaawaanaawa wanna nanana C 9 C 6 Summary Report Request Report Request Confirmation ccccsccecseeceeeeeeeeeeenes C 9 C 7 Detail Report Request Select Provider S asasanaawanaasanaasasanananaasannans C 11 C 8 Detail Report Request Select Report s sss C 11 C 9 Detail Report Request Select Service Period s esse C 12 C 10 Detail Report Request Select Report Format nnne C 16 C 11 Detail Report Request Report Request Confirmation sees seeesse C 17 C 12 Detail Report Request FI MAC Provider Requests cccscceceeeeeeeeeeeeeeeeeeeeeeaeeeas C 18 C 13 Miscellaneous Report Request Select Reports sssssssssse C 20 C 14 Detail Report Request Load Control sssssessss meme C 21 C 15 Detail Report Request Miscellaneous sss C 21 C 16 Miscellaneous System Error Messages sssssssssss meme C 22 C 17 Error Codes in Numeric Order ssssssssssssss meme C 29 DEMECODLIIC IM D 1 User
232. TS 1 8 04 33 PM User Manual February 2009 Version No 2 0 Consolidation Reports 6 3 Provider Statistical and Reimbursement System A Report Details The table below contains report details for the reports that can be generated in the PS amp R System e Report Type This is the identification number assigned to the report e Report Name This is the name description of the report as it will appear in the report header e Service Category This is the service type category Inpatient or Outpatient of the report Users of the redesigned system have the option to request reports by Service Category e Provider Type s This is the type s of provider applicable to the report Users of the redesigned system have the option to request reports for providers by Provider Type e Provider Number Range This is the range of provider numbers applicable to the report This defines the Provider Type s e Cost Report Yes No This column indicates whether the report is needed to complete a Medicare cost report If the report is needed to complete a cost report Yes appears in the column if the report is not needed to complete a cost report No appears in the column If a report is not needed for a cost report the following statement appears in the report header These items are not to be included on the Medicare Cost Reports Note that Yes appears in this column if the report is used for the Cost Report
233. These fields are not populated on this report where the first three positions 044 are rolled up 329 PEP 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 96 Provider Statistical and Reimbursement System Report Type Data Element Description 329 PEP 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 PEP 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 PEP 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 PEP 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 PEP 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 PEP 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 PEP 0623 Displays by itself These fields are not populated on this report 329 PEP All other Rev Codes display as These fields are no
234. These fields are not populated on this report where the first three positions 044 are rolled up 339 SCIC PEP 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 SCIC PEP 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 SCIC PEP 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 SCIC PEP 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 SCIC PEP 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 SCIC PEP 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 SCIC PEP 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 SCIC PEP 0623 Displays by itself These fields are not populated on this report 339 SCIC PEP All other Rev Codes display These fields are not populated on this report as they come in on the claim they do not roll up 339 SCIC 0023 Does not display These fields are not populated on this report 339 SCIC 027X Al
235. This is the sum of the capital amounts for HSP FSP outlier hold harmless disproportionate share adjustment indirect medical education and exception payments User Manual February 2009 Version No 2 0 Report Data B 25 Provider Statistical and Reimbursement System Report Type Data Element Description 410 GROSS REIMBURSEMENT This amount is the sum of total operating and total capital payments 410 CASH DEDUCTIBLE The sum of actual cash deductible amount from the paid claim records 410 BLOOD DEDUCTIBLE The sum of actual blood deductible amount from the paid claim records 410 COINSURANCE The sum of actual coinsurance amount from the paid claim records 410 NET MSP PAYMENTS The sum of net payments made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 410 MSP PASS THRU RECONCILIATI ON This field is informational only and should not be included in the cost report This amount occurs in cases where Medicare has made no payment on the claim yet classifies it as PR Partial Recovery because of the estimated pass through payments The actual pass through amounts will be determined in the cost report The MSP Pass Thru Reconciliation amount must be ignored for cost reporting 410 OTHER ADJUSTMENTS This amount should be zero If
236. ULANCE MILES Accumulated number of miles from paid claims 83Z TOTAL GROSS FEE SCHEDULE AMT This is an accumulation of 10096 fee reimbursed ambulance services 83Z REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 83Z DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 83Z TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 83Z GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis User Manual February 2009 Version No 2 0 Report Data B 63 Provider Statistical and Reimbursement System Report Type Data Element Description 83Z CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 83Z BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 83Z COI NSURANCE The actual coinsurance amount from the paid claim record 83Z NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 83Z NET REI MBURSEMENT This amount represents
237. User Manual February 2009 Version No 2 0 Report Data B 57 Provider Statistical and Reimbursement System Report Type Data Element Description 81P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 81P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 82P CLAIMS Currently this field has no cost report usage 82P UNITS The number of units applicable to each revenue code 82P CHARGES The charges applicable to each revenue code 82P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 82P DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 82P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 82P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 82P OUTLIER The outlier portion of the OPPS payment for the APC 82P GROSS REIMBURSEMENT The gross amo
238. User Manual Fiscal ntermediary Medicare Administrative Contractor Users Medicare Provider Statistical and Reimbursement System PS amp R Centers for Medicare and Medicaid Services CENTERS for MEDICARE amp MEDICAID SERVICES Version 2 0 February 2009 Provider Statistical and Reimbursement System Table of Contents EM nite m 1 1 1 1 Document Conventions nemen ens 1 1 1 2 About this Manual eases Ase 5 3 c riori na kapalan ERR Deoa det te ae yea ex AT dti erede 1 2 2 System Overview and Common Features enean nana nnn nan 2 1 2 1 Access the PS amp R System Website maana awan aasa eee eee eae ener eene 2 1 2 2 PAGS Lay0Ub aa anG ett hi AA E rp deeb en RE TEMERE Me aea 2 2 2 2 1 Header Area use ES oues SU ted need A D ap At ES cota el M dd ie 2 2 272 25 Menu Bal Nadala dan Maa a mee Nh cree i HER ERA o orar UR er enda 2 8 22233 HOME RE ERRORI ana APANG NABAGO dunes DN dee gg NG 2 8 2 3 Field and Control Overview aaaaa nana cece eect eect ANNA GANANG AGANG AGA NA NGA nee nennen enn 2 9 2 3 1 Radio BUTTONS oec reve na AG AA ANAN NA 2 10 2 3 2 Check BOXES ustedes scd ns Eo ah deu Re Et suu te M tes 2 10 2 3 3 Drop Down List yi eee oa nons Dp e IY IR ER RR RR XNpe eevee DER 2 10 2 394 LiISt BOX TTE 2 11 2 3 5 Transfer List Boxes eene eme enses nnns 2 11 23 6 Calendari dic PvE ea ota WE AS Fed e v
239. VICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 04 03 31 04 04 01 04 06 30 04 07 01 04 03 30 04 10 01 04 12 31 04 STATISTIC SECTION DISCHARGES 20 32 0 0 MEDICARE DAYS 228 301 0 0 CLAIMS 20 32 0 0 CHARGE SECTION ACCOMMODATION CHARGES REV CODE DESCRIPTION UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES 0121 MED SUR GY 28ED 228 144 499 00 301 189931 00 0 0 00 0 0 00 TOTAL ACCOMMODATIONS 229 144 499 00 301 189 931 00 0 0 00 o 0 00 ANCILLARY CHARGES REV CODE DESCRIPTION UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES 0250 PHARMACY 744 42 618 60 1 113 56 948 00 o 0 00 0 0 00 0258 IV SOLUTIONS 62 5 900 00 269 27 583 00 0 0 00 0 0 00 0259 DRUGS OTHER ian 26 589 44 4851 39 107 74 0 0 00 0 0 00 0270 MED SUR SUPPLIES 0 0 00 1 113 00 o 0 00 0 0 00 0272 STERILE SUPPLY 0 0 00 3 722 00 0 0 00 0 0 00 0300 LABORATORY or LAB 4 556 00 20 1316 00 o 0 00 0 0 00 0301 LAB CHEMISTRY 55 11 397 00 134 16 779 00 o 0 00 0 0 00 0302 LAB IMMUNOLOGY 0 0 00 1 87 00 0 00 0 0 00 0305 LAB HEMATOLOGY 72 3 827 00 80 3 804 00 o 0 00 0 0 00 0306 LAB BACT MICRO z 2 406 00 20 2 502 00 0 0 00 0 0 00 0209 LAB OTHER 2 164 00 8 5545 00 0 0 00 0 0 00 0320 DX X RAY 5 1 940 00 10 2 908 00 0 0 00 0 0 00 0324 DX X RAY CHEST 5 1 171 00 n 2 553 00 o 0 00 0 0 00 0350 CT SCAN 0 0 00 0 0 00 0 0 00 0 0 00 0351 CT SCAN HEAD 0 0 00 1 1 508 00 0 0 00 0 0 00 035
240. Y Summarizes new technology payments Value code 77 made under the Prospective Payment System 11T IPF ECT Summarizes IPF ECT Inpatient Psych Facility Electro Convulsive Therapy payments made under the Prospective Payment System 11T TOTAL OPERATING PAYMENTS This is the sum of the operating amounts for HSP FSP outlier DSH LI P IME teaching adjustment new technology IPF ECT and exception payments 11T HOSPITAL SPECIFIC This is the hospital specific portion of the PPS payment for capital The field will be zero for providers paid based on the hold harmless old capital or the hold harmless 100 percent federal method and for new hospitals during their first two years of operation 11T FEDERAL SPECIFIC This field includes the federal portion of the PPS payment for capital This field will also include the new capital amount for hospitals paid under the hold harmless old capital method 11T OUTLIER This field will show the outlier portion of the PPS payment for capital 11T HOLD HARMLESS This field shows the hold harmless amount paid for old capital based on the hold harmless old capital method 11T DSH This is the disproportionate share portion of the PPS capital payment 11T INDIRECT MEDI CAL EDUCATION This is the indirect medical education adjustment payment to PPS teaching hospitals applicable to PPS capital payments 11T EXCEPTIONS This is the
241. a Element Description 339 SCIC PEP 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 SCIC PEP 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 SCIC PEP 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 SCIC PEP 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 SCIC PEP 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 SCIC PEP 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 SCIC PEP 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 SCIC PEP 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 SCIC PEP 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 SCIC PEP 062X All revenue code lines These fields are not populated on this report where the first
242. able days that are non covered days This category may be used to prorate the Medicare Days field for cost reporting purposes 11R TOTAL ANCILLARY All Medicare covered charges associated with revenue codes designated as ancillary 11R TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as routine and ancillary 11R HOSPITAL SPECIFIC This line plus any federal specific amounts are the total DRG amounts other than outlier 11R FEDERAL SPECIFIC This line plus any hospital specific amounts are the total DRG amounts other than outlier 11R OUTLIER Summarizes cost outlier payments Value code 17 made under the Prospective Payment System 11R DSH LIP The DSH LIP amount value code 18 shown on the PS amp R report represents interim payments calculated by the PPS Pricer program For cost reporting purposes the DSH LIP amount must be recomputed for qualifying hospitals 11R IME TEACHING ADJ Indirect medical education Teaching adjustment Value Code 19 amount shown on the PS amp R are estimated payments made on a bill by bill basis by the PPS Pricer program For cost reporting purposes the amount must be recomputed 11R NEW TECHNOLOGY Summarizes new technology payments Value code 77 made under the Prospective Payment System 11R IPF ECT Summarizes IPF ECT Inpatient Psych Facility Electro Convulsive Therapy payments made under the Prospective Payment System 11R TOTAL OPERATING PAYMENTS This is the su
243. accine 132 The Outpatient Part B 132 report accumulates data applicable to vaccine services reimbursed based on 100 96 of reasonable cost The items reported on the Outpatient Part B 132 report are included on the Medicare Cost Report 5 6 3 Outpatient Other Vaccines 142 The Outpatient Other Vaccines 142 report accumulates data applicable to vaccine services reimbursed based on 100 percent of reasonable cost The items reported on the Outpatient Other Vaccines 142 report are included on the Medicare Cost Report 5 6 4 SNF Inpatient Vaccine Part B 100 Reasonable Cost 222 The SNF Inpatient Vaccine Part B 100 Reasonable Cost 222 report accumulates data applicable to vaccine services reimbursed based on 100 percent of reasonable cost The items reported on the SNF Inpatient Vaccine Part B 100 Reasonable Cost 222 report are included on the Medicare Cost Report 5 6 5 SNF Outpatient Vaccine Part B 100 Reasonable Cost 232 The SNF Outpatient Vaccine Part B 100 Reasonable Cost 232 report accumulates data applicable to vaccine services reimbursed based on 100 percent of reasonable cost The items reported on the SNF Outpatient Vaccine Part B 100 Reasonable Cost 232 report are included on the Medicare Cost Report 5 6 6 Home Health Vaccine Part B 100 Reasonable Cost 342 The Home Health Vaccine Part B 100 Reasonable Cost 342 report summarizes vaccine servi
244. ach revenue code Note for accommodations revenue codes this may include non covered days 11U CHARGES The charges applicable to each revenue code 11U REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 11U DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 11U TOTAL ACCOMODATIONS This category may include provider liable days that are non covered days This category may be used to prorate the Medicare Days field for cost reporting purposes 11U TOTAL ANCILLARY All Medicare covered charges associated with revenue codes designated as ancillary 11U TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as routine and ancillary 11U HOSPITAL SPECIFIC This line plus any federal specific amounts are the total DRG amounts other than outlier 11U FEDERAL SPECIFIC This line plus any hospital specific amounts are the total DRG amounts other than outlier 11U OUTLIER Summarizes cost outlier payments Value code 17 made under the Prospective Payment System User Manual February 2009 Version No 2 0 Report Data B 27 Provider Statistical and Reimbursement System Report Type Data Element Description 11U DSH
245. ach revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 23P DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 23P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 23P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 23P OUTLIER The outlier portion of the OPPS payment for the APC 23P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 23P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 23P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 23P COI NSURANCE The actual coinsurance amount from the paid claim record 23P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 23P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 23P OTHER ADJUSTMENTS This amount should be zero If not please
246. actual weight non transfer adjusted of the DRG determined by the PPS Pricer program divided by the discharges 11T DISCHARGE FRACTION This field does not apply and will be zero 11T DRG WEIGHT FRACTION This field does not apply and will be zero 11T DRG WEIGHT FRACTION This field does not apply and will be zero DISCHARGES 410 DISCHARGES This field is only valid for inpatient claims This indicates the number of patients discharged 410 MEDICARE DAYS The provider s hospital routine adults and peds days Note The provider s crosswalk may be used to allocate days for cost reporting purposes 410 CLAIMS Currently this field has no cost report usage 410 UNITS The number of units applicable to each revenue code Note for accommodations revenue codes this may include non covered days 410 CHARGES The charges applicable to each revenue code 410 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 410 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 410 TOTAL ACCOMODATI ONS This category may include provider liable days that are non covered days This category may be used to prorate the Medicare Days field for cost reporting purposes 410 TOTAL ANCI LLARY All Medicare covered
247. ade by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 850 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 850 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 125 CLAIMS Currently this field has no cost report usage 125 UNITS The number of units applicable to each revenue code 125 CHARGES The charges applicable to each revenue code 125 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 125 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 125 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 125 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 125 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 125 BLOOD DEDUCTIBLE The actual blood deductible
248. after April 1 2002 The items reported on the Outpatient Ambulance Blend Effective 04 01 02 13Z report are included on the Medicare Cost Report 5 5 3 SNF Ambulance Blend Effective 04 01 02 22Z The SNF Ambulance Blend Effective 04 01 02 22Z report summarizes skilled nursing facility outpatient ambulance services reimbursed under the ambulance fee schedule blended payment which is effective for services provided on or after April 1 2002 The items reported on the SNF Ambulance Blend Effective 04 01 02 22Z report are included on the Medicare Cost Report 5 5 4 SNF Ambulance Blend Effective 04 01 02 23Z The SNF Ambulance Blend Effective 04 01 02 23Z report summarizes skilled nursing facility outpatient ambulance services reimbursed under the ambulance fee schedule blended payment which is effective for services provided on or after April 1 2002 The items reported on the SNF Ambulance Blend Effective 04 01 02 23Z report are included on the Medicare Cost Report 5 5 5 ASC and ASC Fee Schedule Ambulance Blend Effective 04 01 02 83Z The ASC and ASC Fee Schedule Ambulance Blend Effective 04 01 02 83Z report summarizes skilled nursing facility outpatient ambulance services reimbursed under the ambulance fee schedule blended payment which is effective for services provided on or after April 1 2002 The items reported on the ASC and ASC Fee Schedule Ambulance Blend Effective 04 01 02 83Z report a
249. aid claim record 76A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 76A NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 76A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 83A CLAI MS Currently this field has no cost report usage 83A UNITS The number of units applicable to each revenue code 83A CHARGES The charges applicable to each revenue code 83A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 83A DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes User Manual February 2009 Version No 2 0 Report Data B 43 Provider Statistical and Reimbursement System Report Type Data Element Description 83A TOTAL COVERED CHARGES All Medica
250. aim Report Spats 135 138 MSP Cash Deduct bolo MSP Blood Deduct 0 00 MSP Coles s020 Claim merest 0 00 Elected Coles 0 00 Claim Report Spitz 135438 MSP Cash Deduct 000 MSP Blood Deduct 0 00 MSP Coins sec Claim interest 0 00 1218 25 PM User Manual February 2009 Version No 2 0 Outpatient Reports 5 18 Provider Statistical and Reimbursement System Exhibit 5 9 Outpatient xxP Outpatient Prospective Payment System OPPS Payment Reconciliation Detail Report Template Last Page PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page 5 Service Month End N A OUTPATIENT OPPS Report OD44202 Report Run Date 02 07 07 Report Type 12 Provider FYE 12 31 Paid Dates 01 01 04 to 10 01 06 Provider Number T00007 PETERBORO GENERAL HOSPITAL Service Period and Report Type Totals Service Period Reimbursements Additional Info 01 01 2004 01 01 2006 Units Charges GAPC Cas Deduct Blood Deduct Coles MSP MSP Recon Psyc Red Line item Remb Elected Coins GAPC 8 14457 MSP Cash Deduct 0 00 TOTA 39 53436963 3814457 109 09 0 00 1 623 57 200 0 00 6215 09 200 PLUS MSP Sood Deduct 0 00 MSP Coles 0 00 Outlier 2052 Claim Interest soca Gross Raimb 8 165 03 Elected Coins 0 00 LESS Cash Deduct 102 00 Blood Deduct Ko Coins 1 673 57 MP Ko MSP Recon Ko Other Adis 2 00 Paye Red Net Reimb 56 23552 Report Type 13P Totals for PETERBORO GE
251. aims processing Currently this field has no cost report usage 118 IRF PENALTY AMOUNT The 2596 penalty assessed for failure to submit IRF PAI data timely 118 LTCH SHORT STAY OUTLIER PAYMENTS The per diem payments made under PPS to the provider for a patient s stay in the facility prior to being transferred to another facility These payments are included in the net reimbursement field This field is shown for informational purposes only 118 CAP FED SPECIFIC 10096 Note This field equals the federal specific field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period This field should be used by hold harmless providers only 118 CAP OUTLIER 10096 Note This field equals the outlier field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period 118 DRG CMG WEIGHT This is the actual weight of the DRG CMG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS operating payments made to a specific provider 118 WEIGHT DISCHARGES This is the actual weight non transfer adjusted of the DRG determined by the PPS Pricer program divided by the discharges 118 DISCHARGE FRACTION For transfer cases the billed days are divided by th
252. al information section shows the deductible amounts claim interest and MSP Coinsurance The report template also displays a monthly totals section that sums the information from the sections above User Manual Outpatient Reports February 2009 Version No 2 0 5 29 Provider Statistical and Reimbursement System An example of the xx5 Fee Reimbursed Provider Summary report template and the xx5 Fee Reimbursed Payment Reconciliation detail report template follow Exhibit 5 14 Outpatient xx5 Fee Reimbursed Provider Summary Report Template PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page 1 Paid Dates 01 01 03 THRU 10 01 06 OUTPATIENT FEE REIMBURSED Report OD44203 Report Run Date 02 01 07 THESE ITEMS ARE NOT TO BE INCLUDED ON THE MEDICARE COST REPORT Report Type 135 Provider FYE 06 30 Provider Number T00113 SHATTERED HEART TEACHING HOSPITAL SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 03 12 31 03 01 01 04 12 31 04 No Data Requested No Data Requested STATISTIC SECTION CLAIMS 0 10 CHARGE SECTION REV CODE DESCRIPTION UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES 0300 LABORATORY or LAB 0 50 00 6 44 40 0301 LAB CHEMISTRY 0 0 00 21 1 102 80 0305 LAB HEMATOLOGY 0 50 00 4 136 00 0306 LAB BACT MICRO 0 0 00 3 82 00 0307 LAB UROLOGY 0 0 00 1 33 00 0420 PHYSICAL THERP 0 0 00 0 0 00 0430 OCCUPATION THER 0 0 00 0 0 00
253. al and Reimbursement System Field Definition Optional Select the check box to increase the width of the list box containing providers allowing the complete provider name to display in the list box Optional Select the check box to indicate that subunits associated with the provider number s that is all providers owned by a parent provider are to be included in the report Expand Include Subunits 3 Once the provider s have been selected click Continue The following page appears CAIS Provider Statistical amp Reimbursement System AC 14000 eport Request Home Report Inbox Request Report Favorite Requests Request Summary Request Detail Summary Report Request 2 Select Report s C By Service Type All IT Exclude 329 and 339 Patient CBSA Visit Section IT Include 110 DRG Section F Include 1000 Report C By Report Group Search xx OP zi E IT Exclude 329 and 339 Patient CBSA Visit Section IT Include 110 DRG Section F Include 1000 Report C By Report Type Search P LCC j COST REIMBUR F Exclude 329 and 339 Patient CBSA Visit Section IT Include 110 DRG Section Back Continue 4 Selectthe report s to generate for the selected provider s The following table contains a description of each field on the page Field Definition Required if neither By Report Group nor By Report Type is selected Select the By Service Type option and then sel
254. amount from the paid claim record 75P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 75P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 75P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 75P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 55 Provider Statistical and Reimbursement System Report Type Data Element Description 75P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 75P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 76P CLAI MS Currently this field has no cost report usage 76P UNITS The number
255. amount from the paid claim record 852 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance User Manual February 2009 Version No 2 0 Report Data B 73 Provider Statistical and Reimbursement System Report Type Data Element Description 852 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 852 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 230 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 340 CLAIMS Currently this field has no cost report usage 340 UNITS The number of units applicable to each revenue code 340 CHARGES The charges applicable to each revenue code 340 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 340 DESCRIPTION The descr
256. ample of the Summary Report Inbox follows COS Provider Statistical amp Reimbursement System Site Map Announcements FAQ Help AC 14000 User ID TRTEST1 rt Inbox Thursday August 23 Home Report Inbox Request Report Summary Report Inbox Detail Report Inbox Summary Report Inbox pisa Request Name Request Date PDF csv Status Baya ert ah has n TRTEST17 S 9903 08 23 2007 Y Processing r TRTEST17 S TOO007 08 23 2007 318 KB Complete 21 r TRTEST17 S 9900 08 23 2007 80 KB Complete 21 After 21 calendar days with a Status of Complete or Error the report request will no longer appear in this inbox If the Status is Complete it is your responsibility during these 21 days to save the reports to your own computer Refresh Delete 99 PDF files can be viewed and printed using amp dobe Reader software User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 25 Provider Statistical and Reimbursement System An example of the Detail Report Inbox follows CATS Provider Statistical amp Reimbursement System Site Map Announcements 14000 t Inbox Home Report Inbox Request Report Summary Report Inbox Detail Report Inbox Detail Report Inbox Days Left in Inbox Request Name Request Date PDF csv Status 5 TRTEST17 D HALF PIPE 08 23 2007 E Complete 21 TRTEST17 D 9904 08 23 2007 Y Pending IRTEST17 D 9901 08 23 2007 Processing Modi
257. an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 83Z CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 85Z CLAI MS Currently this field has no cost report usage 85Z UNITS The number of units applicable to each revenue code 85Z CHARGES The charges applicable to each revenue code 85Z GROSS FEE AMT This is an accumulation of 10096 fee reimbursed ambulance services Sorted by trips and mileage Not applicable for CAH ambulance services paid at cost 85Z TOTAL AMBULANCE TRI PS Accumulated number of trips from paid claims 85Z TOTAL AMBULANCE MILES Accumulated number of miles from paid claims 85Z TOTAL GROSS FEE SCHEDULE AMT This is an accumulation of 10096 fee reimbursed ambulance services Not applicable for CAH ambulance services paid at cost 85Z REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 85Z DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 85Z TOTAL COVERED CHARGES All Medicare covered charges associated with reve
258. an safely be provided Medical necessity must be established via diagnostic and or other information presented on the claim under consideration before the carrier or insurer will make payment Medically Unnecessary Items and services that are not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a body part In order to be reasonable and necessary the item service must be safe effective appropriate and not experimental or investigational Medicare A nationwide federal health insurance program for people aged 65 and older people with disabilities or people with End Stage Renal Disease ESRD Medicare Part A covers hospital insurance Medicare Part B covers physicians services MSP LCC Medicare Secondary Payer Lower Cost or Charge User Manual February 2009 Version No 2 0 D 5 Glossary Provider Statistical and Reimbursement System Term Definition National Provider Identifier NPI A standard unique health identifier for all health care providers as mandated by the Health Insurance Portability and Accountability Act of 1996 As of May 2007 the NPI is mandated for use on Medicare claims Although not required by the cost reporting system supported by the PS amp R System the NPI will be available in the PS amp R System claim database The National Provider Identifiers NPIs will eventually current Unique Physician Identification
259. ansfer all amounts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 11A 18A 214A 118 and all other inpatient reports are transferred to the cost report 119 CLAIM INTEREST PAYMENTS Sum of interest paid on claims due to untimely claims processing Currently this field has no cost report usage 119 IRF PENALTY AMOUNT The 2596 penalty assessed for failure to submit IRF PAI data timely 119 LTCH SHORT STAY OUTLIER PAYMENTS The per diem payments made under PPS to the provider for a patient s stay in the facility prior to being transferred to another facility These payments are included in the net reimbursement field This field is shown for informational purposes only 119 CAP FED SPECIFIC 10096 Note This field equals the federal specific field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period This field should be used by hold harmless providers only 119 CAP OUTLIER 10096 Note This field equals the outlier field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period 119 DRG CMG WEIGHT This is the actual weight of the DRG CMG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a c
260. apital payment 110 INDIRECT MEDI CAL EDUCATION This is the indirect medical education adjustment payment to PPS teaching hospitals applicable to PPS capital payments 110 EXCEPTI ONS This is the per discharge exception interim payment for capital related costs that qualifying hospitals are entitled to receive in accordance with Medicare payment policy 110 TOTAL CAPITAL PAYMENTS This is the sum of the capital amounts for HSP FSP outlier hold harmless disproportionate share adjustment indirect medical education and exception payments 110 GROSS REIMBURSEMENT This amount is the sum of total operating and total capital payments 110 DEVICE CREDIT This amount represents the credit that a provider received to replace a medical device that may have been defective or under warranty This amount can be identified with a value code of FD on the claim 110 CASH DEDUCTIBLE The sum of actual cash deductible amount from the paid claim records 110 BLOOD DEDUCTIBLE The sum of actual blood deductible amount from the paid claim records User Manual February 2009 Version No 2 0 Report Data B 2 Provider Statistical and Reimbursement System Report Type Data Element Description 110 COINSURANCE The sum of actual coinsurance amount from the paid claim records 110 NET MSP PAYMENTS The sum of net payments made by a higher p
261. are reimbursement This occurs in situations where there is OTAF or MSP LCC 12P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 12P NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 45 Provider Statistical and Reimbursement System Report Type Data Element Description 12P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 12P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 13P CLAIMS Currently this field has no cost report usage 13P UNITS The number of units applicable to each revenue code 13P CHARGES The charges applicable to each revenue code 13P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 13P DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100
262. are Part A providers to request the generation of summary and detail reports for inpatient and outpatient services The reports that can be generated by a specific user are determined by the user s access authority assigned to the user ID For example Medicare Part A providers can only generate summary reports and can submit requests for detail reports to their FI MAC to be generated based on the parameters specified by the provider Once the report request is submitted the FI M AC must approve the request before the report is generated Once a detail report is generated for the provider the FI MAC provides the report to the requesting provider FI MAC users can submit requests for both summary and detail reports to be generated with the results posted to the FI MAC user s report inbox Providers can only generate reports associated with their facility FI MACs can generate reports for all providers and provider types assigned to the FI MAC The PS amp R system provides the following Users can define report selection criteria such as the report groups report types service types and date ranges to include in the reports using the graphical user interface Allproviders can request summary reports directly in the system Providers can submit online requests for detail reports The provider s FI MAC then either approves or denies the request If the request is approved the FUMAC sends the reports to the provider on acceptable media FI MA
263. are not populated on this report 339 PEP 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 123 Provider Statistical and Reimbursement System Report Type Data Element Description 339 PEP 042X All revenue code lines where the first three positions 042 are rolled up These fields are not populated on this report 339 PEP 043X All revenue code lines where the first three positions 043 are rolled up These fields are not populated on this report 339 PEP 044X All revenue code lines where the first three positions 044 are rolled up These fields are not populated on this report 339 PEP 055X All revenue code lines where the first three positions 055 are rolled up These fields are not populated on this report 339 PEP 056X All revenue code lines where the first three positions 056 are rolled up These fields are not populated on this report 339 PEP 057X All revenue code lines where the first three positions 057 are rolled up These fields are not populated on this report 339 PEP 058X All revenue code lines where the first three positions 058 are rolled up These fields are not populated on this report
264. art A information 339 SCIC OTHER FEE REIMBURSEMENTS This is the Part A information 339 SCIC GROSS REIMBURSEMENT This is the Part A information 339 SCIC DEDUCTIBLES This is the Part A information 339 SCIC COINSURANCE This is the Part A information 339 SCIC NET MSP PAYMENTS This is the Part A information 339 SCIC MSP RECONCILIATION This is the Part A information 339 SCIC OTHER ADJ USTMENTS This is the Part A information 339 SCIC NET REIMBURSEMENT This is the Part A information 339 SCIC CLAIM INTEREST PAYMENTS This is the Part A information 339 TOTAL HIPPS REIMBURSEMENT This is the Part A information WITHOUT OUTLIER 339 TOTAL EPISODES WITH OUTLIER This is the Part A information 339 TOTAL HIPPS REIMBURSEMENT WITH This is the Part A information OUTLIER 339 TOTAL OUTLIER REIMBURSEMENTS This is the Part A information 339 TOTAL PROSTHETIC ORTHOTIC This is the Part A information DEVICES 339 TOTAL DME This is the Part A information 339 TOTAL OXYGEN This is the Part A information 339 TOTAL OTHER FEE REIMBURSEMENTS This is the Part A information 339 TOTAL GROSS REI MBURSEMENT This is the Part A information 339 TOTAL DEDUCTIBLES This is the Part A information 339 TOTAL COINSURANCE This is the Part A information 339 TOTAL NET MSP PAYMENTS This is the Part A information 339 TOTAL MSP RECONCILIATION This is the Part A information 339 TOTAL OTHER ADJ USTMENTS This is the Part A information 339 TOTAL NET REIMBURSEMENT This is the Part A info
265. art A information DEVICES 339 SCIC PEP DME This is the Part A information 339 SCIC PEP OXYGEN This is the Part A information 339 SCIC PEP OTHER FEE This is the Part A information REI MBURSEMENTS 339 SCIC PEP GROSS REIMBURSEMENT This is the Part A information 339 SCIC PEP DEDUCTIBLES This is the Part A information 339 SCIC PEP COINSURANCE This is the Part A information 339 SCIC PEP NET MSP PAYMENTS This is the Part A information 339 SCIC PEP MSP RECONCILIATI ON This is the Part A information 339 SCIC PEP OTHER ADJUSTMENTS This is the Part A information 339 SCIC PEP NET REIMBURSEMENT This is the Part A information 339 SCIC PEP CLAIM INTEREST PAYMENTS This is the Part A information 339 SCIC EPISODES WITHOUT OUTLIER This is the Part A information 339 SCIC HIPPS REIMBURSEMENT This is the Part A information WITHOUT OUTLIER 339 SCIC EPISODES WITH OUTLIER This is the Part A information User Manual February 2009 Version No 2 0 Report Data B 135 Provider Statistical and Reimbursement System Report Type Data Element Description 339 SCIC HIPPS REIMBURSEMENT WITH This is the Part A information OUTLIER 339 SCIC OUTLIER REIMBURSEMENTS This is the Part A information 339 SCIC PROSTHETIC ORTHOTIC This is the Part A information DEVICES 339 SCIC DME This is the Part A information 339 SCIC OXYGEN This is the P
266. ase mix index CMI for PPS operating payments made to a specific provider User Manual February 2009 Version No 2 0 Report Data B 10 Provider Statistical and Reimbursement System Report Type Data Element Description 119 WEIGHT DISCHARGES This is the actual weight non transfer adjusted of the DRG determined by the PPS Pricer program divided by the discharges 119 DISCHARGE FRACTION For transfer cases the billed days are divided by the average length of stay for the DRG and the result is entered in this field The amounts in this field cannot exceed 1 0000 For non transfer cases the amount 1 0000 will always appear in this field 119 DRG WEIGHT FRACTION This is the actual weight of the DRG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS operating payments made to a specific provider 119 DRG WEIGHT FRACTION DISCHARGES This field reflects the DRG weight times the discharge fraction divided by the discharges This amount can be used to calculate a transfer adjusted case mix 11K DISCHARGES This field is only valid for inpatient claims This indicates the number of patients discharged 11K MEDICARE DAYS The provider s hospital routine adults and peds days Note The provider s crosswalk may be used to allocate days for cost repor
267. ash deductible amount from the paid claim record 222 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 222 COINSURANCE The actual coinsurance amount from the paid claim record 222 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 222 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 222 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 232 CLAIMS Currently this field has no cost report usage 232 UNITS The number of units applicable to each revenue code User Manual February 2009 Version No 2 0 Report Data B 67 Provider Statistical and Reimbursement System Report Type Data Element Description 232 CHARGES The charges applicable to each revenue code 232 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 232 DESCRIPTION The description of each revenue code an
268. ass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 42 Provider Statistical and Reimbursement System Report Type Data Element Description 75A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 76A CLAI MS Currently this field has no cost report usage 76A UNITS The number of units applicable to each revenue code 76A CHARGES The charges applicable to each revenue code 76A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 76A DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 76A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 76A GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 76A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 76A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 76A COI NSURANCE The actual coinsurance amount from the p
269. atient Part A 110 report are included on the Medicare Cost Report The Inpatient Fee Reimbursed 115 report is generated automatically when the Inpatient Part A 110 report is requested 4 2 10 I npatient Psych Part A PPS 11U The Inpatient Psych Part A PPS 11U report summarizes Inpatient Part A PPS services for Inpatient Psychiatric Facility Hospitals The items reported on the Inpatient Psych Part A PPS 11U report are included on the Medicare Cost Report 4 2 11 Inpatient Psych PPS Interim Bills 11V The Inpatient Psych PPS Interim Bills 11V report summarizes Inpatient Part A hospital services reimbursed under the Inpatient Psychiatric Facility PPS payment system that have been billed on an interim basis i e a bill frequency code of 2 or 3 The items reported on the Inpatient Psych PPS Interim Bills 11V report are included on the Medicare Cost Report 4 2 12 Religious Non Medical Inpatient Part A 410 The Religious Non Medical Inpatient Part A 410 report summarizes the Medicare days discharges charges deductibles coinsurance and net reimbursement for a reporting period Religious Non Medical facilities typically have relatively low Medicare utilization and the majority of their charges are for routine inpatient care The items reported on the Religious Non Medical Inpatient Part A 410 report are included on the Medicare Cost Report User Manual Inpatient Reports Fe
270. be valid entry contains an invalid month day and or year All Entry must be less than or Error E007 Paid To date E007 equal to the default date must be on or before Default Boundary Date boundary date CMS User the latest paid date from any paid claim file FI MAC Admin User the latest paid date from a paid claim file loaded for that FI Parent Provider and Freestanding Child Provider User the latest paid date from a paid claim file loaded for the provider s Fl All Entry must be greater than or Error E312 Paid Dates do E312 equal to the Paid Date From not have a valid date range Date From from date To to date Parent Provider is Parent If you are requesting a report Warning W008 Service dates W008 no longer an Provider from when a parent provider requested do not coincide with owner of a child owned a child provider it requestor access rights for must be in the range of when Provider ID These dates will the Provider owned the child be modified on the Confirm Report Request screen to reflect valid access dates Do you wish to Continue Parent Provider Parent If you are requesting a report Error E323 Service dates E323 does not have Provider from when a parent provider requested do not coincide with access rights for the dates requested owned a child provider it must be in the range of when the Provider owned the child requestor access rights for Provider provider nu
271. bruary 2009 Version No 2 0 Glossary D 3 Provider Statistical and Reimbursement System Term Definition Health Insurance Portability and Accountability Act HI PAA of 1996 A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships Title II Subtitle F of HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data to specify what medical and administrative code sets should be used within those standards to require the use of national identification systems for health care patients providers payers or plans and employers or sponsors and to specify the types of measures required to protect the security and privacy of personally identifiable health care information Also known as the Kennedy Kassebaum Bill the Kassebaum Kennedy Bill K2 or Public Law 104 191 HIPAA also e limits how companies can use your pre existing medical conditions to keep you from getting health insurance coverage e Usually gives you credit for health coverage you have had in the past e may give you special help with group health coverage when you lose coverage or have a new dependent and e generally guarantees your right to renew your health coverage HIPAA does not replace the states roles as primary regulators of insurance Health Maintenance Organization HMO An entity that provide
272. bruary 2009 Version No 2 0 4 14 Provider Statistical and Reimbursement System 4 3 18x and 21x Report Template The 18x and 21x template reports are processed at the claim level There is a summary report and a detail report associated with each report within the 18x and 21x report templates The Inpatient 18x and 21x Provider Summary reports display summary statistics charges reimbursements additional information for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The data displayed in each section is determined by the report selected for generation For example if the Swing Bed SNF MSP LCC 18A report is generated the report contains claims where the claim level MSP LCC indicator is M or the claim level indicator is FR Full Recovery The statistics section displays the number of discharges Medicare days and number of claims for each of the reporting periods presented on the report The charge section displays the number of units and the total dollar amount of the revenue code being reported for accommodation charges and ancillary charges for example pharmacy IV solutions drugs medical supplies sterile supplies and laboratory charges The Reimbursement Section displays gross reimbursement amounts cash deductible blood deductible coinsurance
273. bursement System A brief description of these reports is provided in the following sections 5 8 1 Inpatient Part B Cost Reimbursed 120 The Inpatient Part B Cost Reimbursed 120 report accumulates data for services normally covered under Part A that have become covered under Part B For reimbursement purposes Inpatient Part B and Outpatient Part B are combined on the Medicare Cost Report The items reported on the Inpatient Part B Cost Reimbursed 120 report are included on the Medicare Cost Report 5 8 2 Outpatient Cost Reimbursed 130 The Outpatient Cost Reimbursed 130 report summarizes hospital outpatient data reimbursed on a reasonable cost basis for all services other than diagnostic services This report also summarizes laboratory services reimbursed on a fee schedule in a supplemental report The items reported on the Outpatient Cost Reimbursed 130 report are included on the Medicare Cost Report 5 8 3 Outpatient Other All Other Cost Reimbursed 140 The Outpatient Other All Other Cost Reimbursed 140 report summarizes hospital other Part B data for bill type 14x reimbursed on a reasonable cost basis The items reported on the Outpatient Other All Other Cost Reimbursed 140 report are included on the Medicare Cost Report 5 8 4 SNF Inpatient Part B Cost Reimbursed 220 The SNF Inpatient Part B Cost Reimbursed 220 report summarizes SNF Inpatient Part B services The items reported on the
274. care Open Enrollment November 15th December 31 2008 Cms Issues Agent Compensation Requirements 2008 Actuarial Report On The Financial Outlook Of Medicaid Medicaid Spending Projected To Rise Much Faster Than The Economy 2009 Medicare Prescription Drug And Medicare Advantage Plan Options DON T GET THE FLU DON T SPREAD THE FLU cdc gov flu 4 Top 10 Links 1 Manuals 2 Medicare Coverage Database 3 CMS Forms 4 Transmittals 5 Medicare Coverage General Information 6 MLN Products 7 MLN Matters Articles 8 Physi Eee Schedule Looku 9 Physician Quality Reporting Initiative 10 National Provider Identifier Standard Do you help someone with Medicare G ves No You are a caregiver Medicare has information for you Learn More Medicare modicare gov caregivers DIA Peopte CHANGE P eov Sop amp Compare Now 1 Medicare Annual Open Enrollment November 15 December 31 Freedom of Information Act No Fear Act Centers for Medicare amp Medicaid Services 7500 Security Boulevard Baltimore MD 21244 www4 User Manual February 2009 Version No 1 System Overview and Common Features 2 4 Provider Statistical and Reimbursement System 2 2 1 2 Site Map The Site Map hyperlink when selected displays a visual structure of the pages within the PS amp R System to assist users to navigate within the PS amp R System The Site Map page follows Exhibit 2 4 Site Map Page
275. ces provided by rural health clinics The items reported on the Home Health Vaccine Part B 10096 Reasonable Cost 342 report are included on the Medicare Cost Report 5 6 7 Clinic Rural Health Vaccine Part B 10096 Reasonable Cost 712 The Clinic Rural Health Vaccine Part B 10096 Reasonable Cost 712 report summarizes vaccine services provided by rural health clinics The items reported on the Clinic Rural Health Vaccine Part B 100 Reasonable Cost 712 report are included on the Medicare Cost Report 5 6 8 Federally Qualified Health Center Vaccine Part B 100 Reasonable Cost 732 The Federally Qualified Health Center Vaccine Part B 10096 Reasonable Cost 732 report summarizes vaccine services provided by Federally Qualified Health Centers The items reported on the Federally Qualified Health Center Vaccine Part B 100 Reasonable Cost 732 report are included on the Medicare Cost Report User Manual Outpatient Reports February 2009 Version No 2 0 5 28 Provider Statistical and Reimbursement System 5 6 9 Rehabilitation Facility Vaccine Part B 100 Reasonable Cost 742 The Rehabilitation Facility Vaccine Part B 100 Reasonable Cost 742 report summarizes vaccine services provided by rehabilitation facilities The items reported on the Rehabilitation Facility Vaccine Part B 100 Reasonable Cost 742 report are included on the Medicare Cost Report 5 6 10 Comprehensive
276. cine Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes User Manual February 2009 Version No 2 0 Report Details A 3 Provider Statistical and Reimbursement System Report Type Report Name Service Category Provider Type s Provider Number Range Cost Report Yes No 125 Inpatient Part B Fee Reimbursed Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 No 13A Outpatient All Other MSP LCC Outpatient Either Hospital or ESRD 0001 0999 1200 1399 2000 2299 2300 2899 2900 2999 3025 3099 3300 3399 3500 3799 4000 4499 5001 5999 TO00 T999 M300 M399 R300 R399 No 13P Outpatient OPPS Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 13Z Outpatient Ambulance Blend Effective 04 01 02 Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes User Manual February 2009 Version No 2 0 Report Details A 4 Provider Statistical and Reimbursement System Report Type Report Name Service Category Provider Type s Provider Numb
277. claim record 835 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 835 COINSURANCE The actual coinsurance amount from the paid claim record 835 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 835 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 835 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 855 CLAIMS Currently this field has no cost report usage 855 UNITS The number of units applicable to each revenue code 855 CHARGES The charges applicable to each revenue code 855 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 855 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 855 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 855 GROSS
278. claims the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 18A and 21A are transferred to the cost report 210 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 21A ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP claims the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 18A and 21A are transferred to the cost report 180 RUC This field reflects the units paid per RUG category 180 RUB This field reflects the units paid per RUG category 180 RUA This field reflects the units paid per RUG category 180 RUX This field reflects the units paid per RUG category 180 RUL This field reflects the units paid per RUG category 180 RVC This field reflects the units paid per RUG category 180 RVB This field reflects the units paid per RUG category 180 RVA This field reflects the units paid per RUG category 180 RVX This field reflects the units paid per RUG catego
279. claims payment timeliness CPT provisions 14P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 22P CLAIMS Currently this field has no cost report usage 22P UNITS The number of units applicable to each revenue code 22P CHARGES The charges applicable to each revenue code 22P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 22P DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 22P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 22P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 22P OUTLIER The outlier portion of the OPPS payment for the APC 22P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 22P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 22P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 22P COINSURANCE The actual coinsurance amount from the paid claim record 22P NET MSP PAYMENTS The net payment made by a higher priority payer under the
280. claims payment timeliness CPT provisions 225 CLAIMS Currently this field has no cost report usage 225 UNITS The number of units applicable to each revenue code 225 CHARGES The charges applicable to each revenue code 225 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 225 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 225 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 225 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 225 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record User Manual February 2009 Version No 2 0 Report Data B 81 Provider Statistical and Reimbursement System Report Type Data Element Description 225 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 225 COINSURANCE The actual coinsurance amount from the paid claim record 225 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coin
281. clicked this radio button must be clicked C 3 Summary Report Request Select Report s The Summary Report Request Select Report s page error messages are presented in the following table Exhibit C 3 Summary Report Request Select Report s Page Error Messages Form Field User Type Validation Error Message ID By Service Type All If By Report Type radio Error E034 No reports were E034 Radio Button button or By Report Number selected radio button is not clicked this radio button must be clicked By Report Group All If radio button is clicked at Error E036 By Report E036 Radio Button least one report group must group option selected but no be selected report group s chosen If By Service Type radio Error E034 No reports were E034 button or By Report Type selected radio button is not clicked this radio button must be clicked By Report Type All If radio button is clicked at Error E037 By Report Type E037 Radio Button least one report type must be option selected but no report selected type s chosen If By Service Type radio Error E034 No reports were E034 button or By Report Group radio button is not clicked this radio button must be clicked selected User Manual February 2009 Version No 2 0 Error Messages C 3 Provider Statistical and Reimbursement System Form Fi
282. covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 752 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 752 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 752 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 752 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 752 COINSURANCE The actual coinsurance amount from the paid claim record 752 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 752 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 71 Provider Statistical and Reimbursement System Report Type Data Element Description 752 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 762 CLAIMS Currently th
283. ct MS Coins Cam interest 006 0 00 0 00 0 00 13A 006 000 006 006 13A soso 000 0 00 0 00 1217 55 PM User Manual February 2009 Version No 2 0 Outpatient Reports 5 12 Exhibit 5 5 Payment Reconciliation Detail Report Template Last Page Program ID REDESIGN Service Month End N A Report Run Date 02 07 07 Provider FYE 12 21 Provider Number T00007 PETERBORO GENERAL HOSPITAL Service Period 01 01 2004 01 01 2006 Report Type 13A Totals for PETERBORO GENERAL HOSPITAL Feb 7 2007 PAYMENT RECONCILIATION REPORT OUTPATIENT ALL OTHER MSP LCC Service Period and Report Type Totals Units Units Charges 3480 10 3484 NI Charges 3 480 10 3 484 13 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Reimbursements Gross Reim 3 263 28 LESS Cash Deduct 700 00 Sicod Dedect 0 00 Coles 579204 NGP 5218822 Pac Red Net Reimb 7323 Reimbursements Gross Reim 3 263 29 LESS Cash Deduct 200 00 Sood Deduct 0 00 Coins 732 04 MSP 52 158 22 Psyc Red ga Net Reimb 33 Provider Statistical and Reimbursement System Outpatient xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Page 2 Report OD44202 Report Type 134 Paid Dates 01 01 04 to 10 01 06 Additional information MS Cash Deduct MS Blood Deduct MS Coins Claim Interest sees 28888 Additional information MS Cash Deduct 000 MS
284. ct Paid To Date All Only numeric characters Error E042 Paid To Date entry contains a non numeric character or is not in MM DD YYYY format E042 Select Paid To Date All Entry must be in MM DD YYYY format Error E042 Paid To Date entry contains a non numeric character or is not in MM DD YYYY format E042 Service Period To Dates in Selected Service Periods Table All Field must not be null Error E042 Paid Date s entry contains a non numeric character or is not in MM DD YYYY format E046 CSV Radio Button All If the PDF radio button is not selected this must be selected Error E046 No report format was selected Please choose a report format before continuing E046 CSV Radio Button CMS FI MAC If the PDF radio button is not selected this must be selected Error E046 No report format was selected Please choose a report format before continuing E046 PDF Radio Button All If the CSV radio button is not selected this must be selected Error E046 No report format was selected Please choose a report format before continuing E046 PDF Radio Button CMS FI MAC If the CSV radio button is not selected this must be selected Error E046 No report format was selected Please choose a report format before continuing User Manual February
285. d Note Primary payments are first allocated to the extent of any deductibles or coinsurance 832 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 832 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 852 CLAIMS Currently this field has no cost report usage 852 UNITS The number of units applicable to each revenue code 852 CHARGES The charges applicable to each revenue code 852 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 852 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 852 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 852 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 852 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 852 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 852 COINSURANCE The actual coinsurance
286. d by the FISS financial cycle do balance as processed by the PS amp R load function W016 Load Control Load FI MAC Admin After clicking the Certify Warning W016 By Certification button button for a load that has failed the following warning is displayed clicking Continue you are certifying that you agree with the following statement acknowledge that this load failed User Manual February 2009 Version No 2 0 Error Messages C 46 Provider Statistical and Reimbursement System D Glossary This appendix contains a list of terms and abbreviations that are relevant to the PS amp R System Exhibit D 1 Glossary Term Definition Active A provider that is active for a Fiscal Intermediary Fiscal Intermediaries service many providers When a provider obtains a Provider Agreement with Medicare and a Fiscal Intermediary Medicare Administrative Contractor is assigned that provider is said to be active for that Fiscal Intermediary Medicare Administrative Contractor When the provider is terminated from Medicare or is assigned to a different FI MAC the provider is said to be inactive for that FI MAC any provider that is inactive for a FI MAC is one that the FI MAC used to service but no longer does ASC Ambulatory Surgical Surgery Center Centers for Medicare and Medicaid Services CMS The Health and Human Services HHS agency responsible for Medicare and
287. d its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 232 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 232 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 232 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 232 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 232 COINSURANCE The actual coinsurance amount from the paid claim record 232 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 232 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 232 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 342 CLAIMS Currently this field has no cost report usage 342 UNITS The number of units applicable to each revenue code 342 CHARGES The charges applicable to each revenue code 342 REV CODE Each revenue code and its associated covered units and
288. d on this report where the first three positions 027 excluding 0274 are rolled up 329 FULL 0274 Displays by itself These fields are not populated on this report 329 FULL 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 FULL 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 FULL 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 FULL 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 FULL 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 100 Provider Statistical and Reimbursement System Report Type Data Element Description 329 FULL 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 FULL 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 FULL 058X All revenue code lines These fields are not pop
289. de 821 Cond Code 73 The number of units applicable to each revenue code 720 UNITS Rev Code 821 Cond Code 74 The number of units applicable to each revenue code 720 UNITS Rev Code 821 Cond Code 76 The number of units applicable to each revenue code 720 UNITS Rev Code 831 Cond Code 71 The number of units applicable to each revenue code 720 UNITS Rev Code 831 Cond Code 72 The number of units applicable to each revenue code 720 UNITS Rev Code 831 Cond Code 73 The number of units applicable to each revenue code 720 UNITS Rev Code 831 Cond Code 74 The number of units applicable to each revenue code 720 UNITS Rev Code 831 Cond Code 76 The number of units applicable to each revenue code 720 UNITS Rev Code 841 Cond Code 73 The number of units applicable to each revenue code 720 UNITS Rev Code 841 Cond Code 74 The number of units applicable to each revenue code 720 UNITS Rev Code 851 Cond Code 73 The number of units applicable to each revenue code 720 UNITS Rev Code 851 Cond Code 74 The number of units applicable to each revenue code 720 COV CHG PYMTS The charges applicable to each revenue code 720 AVG PYMT RATE Rev Code 821 The average composite rate reimbursement by treatment Cond Code 71 type 720 AVG PYMT RATE Rev Code 821 The average composite rate reimbursement by treatment Cond Code 72 type 720 AVG PYMT RATE Rev Code 821 The average composite rate reimbursement by t
290. des 11V TOTAL ACCOMODATI ONS This category may include provider liable days that are non covered days This category may be used to prorate the Medicare Days field for cost reporting purposes 11V TOTAL ANCILLARY All Medicare covered charges associated with revenue codes designated as ancillary 11V TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as routine and ancillary 11V HOSPITAL SPECIFIC This line plus any federal specific amounts are the total DRG amounts other than outlier 11V FEDERAL SPECIFIC This line plus any hospital specific amounts are the total DRG amounts other than outlier 11V OUTLIER Summarizes cost outlier payments Value code 17 made under the Prospective Payment System User Manual February 2009 Version No 2 0 Report Data B 30 Provider Statistical and Reimbursement System Report Type Data Element Description 11v DSH LIP The DSH LIP amount value code 18 shown on the PS amp R report represents interim payments calculated by the PPS Pricer program For cost reporting purposes the DSH LIP amount must be recomputed for qualifying hospitals 11V IME TEACHING AD Indirect medical education Teaching adjustment Value Code 19 amount shown on the PS amp R are estimated payments made on a bill by bill basis by the PPS Pricer program For cost reporting purposes the amount must be recomputed 11V NEW TECHNOL
291. descriptive purposes Text Box 1 Search List Box 1 Available Items and List Box 2 Selected Items List Box 1 contains all items from which the user can choose in alphabetical or numerical order the user indicates the choice by transferring one or more of these items to List Box 2 Any item in List Box 2 is considered a selected item To transfer one item from List Box 1 to List Box 2 the user must first locate the specific item in List Box 1 This can be performed either by manually scrolling through the list box until the desired item is located or by typing the selection criteria in the Search text box The list box automatically scrolls to the location in the list based on the data entered in the Search text box Once the item is located in List Box 1 the user must transfer the item to List Box 2 in order for the item to be selected To do this the user must first click the item to select the item Then the user must click the right transfer button cp to move the item from List Box 1 to List Box 2 Multiple items can be selected using Microsoft Window s standard CTRL click or SHIFT click functions Any or all items that are moved to List Box 2 can be removed by highlighting the item s to be removed and clicking the left transfer button Ail This moves the highlighted item s from List Box 2 to List Box 1 2 3 6 Calendar The Calendar enables a user to scroll through a calendar to locate and select a spec
292. directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 11A 18A 21A 118 and all other inpatient reports are transferred to the cost report 118 DISCHARGES This field is only valid for inpatient claims This indicates the number of patients discharged 118 MEDICARE DAYS The provider s hospital routine adults and peds days Note The provider s crosswalk may be used to allocate days for cost reporting purposes Note For Report Type 118 the Medicare Days are HMO days 118 CLAIMS Currently this field has no cost report usage 118 UNITS The number of units applicable to each revenue code Note for accommodations revenue codes this may include non covered days 118 CHARGES The charges applicable to each revenue code 118 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes User Manual February 2009 Version No 2 0 Report Data B 4 Provider Statistical and Reimbursement System Report Type Data Element Description 118 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 118 TOTAL ACCOMODATIONS This category may include pro
293. e asterisk e backslash e left parenthesis e right parenthesis e percent sign yr 669966 If any special characters not defined above for example lt 5 are entered in any data entry fields the system returns the E331 error and redirects the user to the Login page The Your Request Name field cannot contain any of the following characters 2 lt gt Refer to Appendix C Error Messages for additional information about this error message User Manual System Overview and Common Features February 2009 Version No 1 2 14 Provider Statistical and Reimbursement System 2 4 Useful Internet Explorer Keystrokes The following table provides a summary of useful Internet Explorer keystrokes used to navigate pages in the FID Table 2 1 Useful I E Keystrokes Action Key Move forward and backward through links and Tab to move forward Shift Tab to move backward form controls on a page Activate a link Enter Select and deselect checkboxes Spacebar Select from a group of radio buttons Up Arrow Down Arrow Select a choice from a selection box Up Arrow Down Arrow or the First Letter Alternatively the Alt Down Arrow key combination can also be used to first open the list of choices To make multiple selections in a list box Tab to move into the list box Shift F8 to move into Multi Select mode Up Arrow Down Arrow to move through the lis
294. e oii ret REOR ERE TR E RH URN NA pee ER PINE 4 4 4 2 1 Inpatient Fee Reimbursed 115 cccccce cece eee eee aa 4 11 4 2 2 Inpatient Part A MSP LCC 11A 2 m mee 4 13 4 2 3 Inpatient Long Term Care Part A PPS Interim Bills 11T 4 13 4 2 4 Inpatient Long Term Care Part A PPS 115 sssssssee 4 13 4 2 5 Inpatient Rehabilitation PPS Interim Bills 11K 4 14 4 2 6 Inpatient Part A Managed Care 118 2 4 14 4 2 7 Inpatient Rehabilitation Part A PPS 1IR ccccccceeseeeeeeeeeeneeees 4 14 4 2 8 Inpatient PPS Interim Bills 119 sse 4 14 4 2 9 Inpatient Part A 110 4 14 4 2 10 Inpatient Psych Part A PPS 11U ssssssssseeen mme 4 14 4 2 11 Inpatient Psych PPS Interim Bills 11V essen 4 14 4 2 12 Religious Non Medical Inpatient Part A 410 ssuesssse 4 14 4 3 18x and 21x Report Template munuanan nananana anan nananana eee eee ae hee hene nnns 4 15 4 3 1 Swing Bed SNF MSP LCC 18A 32 nemen 4 19 4 3 2 Swing Bed SNF 180 cccccecee eee eee eee esas cess em eme eese nnns 4 19 4 3 3 SNF Inpatient Part A MSP LCC 214 csse 4 20 4 3 4 SNF Inpatient Part A PPS 210 2 20 cece cece eaeeeaeeaeeeneeeneeas 4 20 5 Outpatient Reports AA AA 5 1 5 1 Outpatient Report Type Assignment
295. e average length of stay for the DRG and the result is entered in this field The amounts in this field cannot exceed 1 0000 For non transfer cases the amount 1 0000 will always appear in this field 118 DRG WEIGHT FRACTION This is the actual weight of the DRG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS operating payments made to a specific provider 118 DRG WEIGHT FRACTION DISCHARGES This field reflects the DRG weight times the discharge fraction divided by the discharges This amount can be used to calculate a transfer adjusted case mix User Manual February 2009 Version No 2 0 Report Data B 7 Provider Statistical and Reimbursement System Report Type Data Element Description 119 DISCHARGES This field is only valid for inpatient claims This indicates the number of patients discharged 119 MEDICARE DAYS The provider s hospital routine adults and peds days Note The provider s crosswalk may be used to allocate days for cost reporting purposes 119 CLAIMS Currently this field has no cost report usage 119 UNITS The number of units applicable to each revenue code Note for accommodations revenue codes this may include non covered days 119 CHARGES The charges applicable to each revenue code 119 REV CODE Each
296. e code User Manual February 2009 Version No 2 0 Report Data B 38 Provider Statistical and Reimbursement System Report Type Data Element Description 23A CHARGES The charges applicable to each revenue code 23A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 23A DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 23A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 23A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 23A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 23A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 23A COINSURANCE The actual coinsurance amount from the paid claim record 23A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 23A NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi we
297. e entered criteria Optional Select the check box to exclude the 329 and 339 Patient CBSA visit section Optional Select the check box to include the DRG section for the reports in the request I nclude 110 DRG Section is valid only if By Report Group is 11x Optional Select the check box to include the Consolidated Summary of All Report Types Report 1000 with the request Required if neither By Service Type nor By Report Group is selected Select the By Report Type option and then select the report type to include in the report Once a report type is highlighted click the 55 button to select the report type Once a report type is selected highlight the report type from the list of selected report types and click the button to remove the report type To locate a report type in the list of report types type the desired report type in the Search text box to scroll to the report type based on the entered criteria Optional Select the check box to exclude the 329 and 339 Patient CBSA visit section Optional Select the check box to include the DRG section for the reports in the request I nclude 110 DRG Section is valid only if By Report Type is 110 User Manual February 2009 Version No 2 0 Performing Tasks in the PS amp R 3 10 Provider Statistical and Reimbursement System 5 Click Continue to continue to the next page to specify the service periods and claim paid dates to include in the report s o
298. e first three positions 059 are rolled up 339 SCIC PEP 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 SCIC PEP 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 SCIC PEP 0623 Displays by itself These fields are not populated on this report 339 SCIC PEP All other Rev Codes display These fields are not populated on this report as they come in on the claim they do not roll up 339 SCIC 0023 Does not display These fields are not populated on this report 339 SCIC 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 SCIC 0274 Displays by itself These fields are not populated on this report 339 SCIC 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 119 Provider Statistical and Reimbursement System Report Type Data Element Description 339 SCIC 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 SCIC 043X All revenue code lines These fields are not
299. e following sections document the processing requirements for a claim to be presented on these outpatient reports 5 1 1 72x Hospital Based or Independent Renal Dialysis Center The 72x claims are assigned to the Hospital Based or Independent Renal Dialysis Center MSP LCC 72A report Hospital Based or Independent Renal Dialysis Center Composite Rate Services 720 report Hospital Based or Independent Renal Dialysis Center Fee Reimbursed 725 report Outpatient Part B Vaccine 132 report and Outpatient Cost Reimbursed 130 report if the type of bill is 72x If the MSP LCC Indicator is M or the Full Recovery indicator is FR the claims are displayed on the Hospital Based or Independent Renal Dialysis Center MSP LCC 72A report Note that the MSP LCC and Full Recovery indicators are at the claim level If either indicator is present the entire claim is presented on the Hospital Based or Independent Renal Dialysis Center MSP LCC 72A report If the ESRD Revenue Code is 821 831 841 or 851 the claim lines are presented on the Hospital Based or Independent Renal Dialysis Center Composite Rate Services 720 report If a HCPCS Code is present on a claim line and the corresponding Total Fee Schedule amount is greater than zero 0 or if the Revenue Code is 0634 EPO 0635 EPO 0825 0835 0845 or 0855 Home Support the claim line is presented on the Hospita
300. e for SCIC PEP REI MBURSEMENTS 399 SCIC PEP GROSS REIMBURSEMENT Part B Gross Reimb for SCI C PEP 399 SCIC PEP DEDUCTIBLES Part B Deduct for SCIC PEP 399 SCIC PEP COINSURANCE Part B Coins for SCI C PEP 399 SCIC PEP NET MSP PAYMENTS Part B MSP Recon for SCIC PEP 399 SCIC PEP MSP RECONCILIATION Part B Net MSP Payment for SCI C PEP 399 SCIC PEP OTHER ADJUSTMENTS Part B Other Adjust for SCIC PEP 399 SCIC PEP NET REIMBURSEMENT Part B Net Reimb for SCIC PEP 399 SCIC PEP CLAIM INTEREST PAYMENTS Part B Claim Interest Payments for SCIC PEP 399 SCIC EPISODES WITHOUT OUTLIER Part B of Episodes w o outlier for SCIC 399 SCIC HIPPS REIMBURSEMENT Part B HIPPS Reimb w o outlier for SCIC WITHOUT OUTLIER 399 SCIC EPISODES WITH OUTLIER Part B of Episodes with outlier for SCIC 399 SCIC HIPPS REIMBURSEMENT WITH Part B HIPPS Reimb with outlier for SCIC OUTLIER 399 SCIC OUTLIER REIMBURSEMENTS Part B outlier reimb for SCIC 399 SCIC PROSTHETI C ORTHOTIC Part B P amp O for SCIC DEVICES 399 SCIC DME Part B DME for SCIC 399 SCIC OXYGEN Part B Oxygen for SCIC 399 SCIC OTHER FEE REI MBURSEMENTS Part B Other Fee for SCIC 399 SCIC GROSS REI MBURSEMENT Part B Gross Reimb for SCIC 399 SCIC DEDUCTIBLES Part B Deduct for SCIC 399 SCIC COINSURANCE Part B Coins for SCIC 399 SCIC NET MSP PAYMENTS Part B MSP Recon for SCIC 399 SCIC MSP RECONCILIATI ON Part B Net MSP Payment for SCIC User Manual February 2009 Version No
301. e lost if the provider Select Reports selection is changed Screen 1f provider selection is changed the report types needs to be reselected Do you wish to go back to the Provider Selection List FI MAC Provider FI MAC If Providers have been Warning W006 Requests Admin changed by the FI MAC The original requestor s Select admin display warning provider selection has been Provider s message after the admin changed Screen clicks Opu from the The selected provider s may Select Provider s screen not belong to the requestor Do you wish to continue FI MAC Provider FI MAC If Service Period Dates have Warning W007 Requests Admin been changed by the FI MAC The selected Service Periods Select Service admin display warning may be outside the Period Date s message after the admin requestor s selected range Screen CICK Continue FORE The new Service Periods may Select Service Period Date s contain data which does not Screen belong to the requestor Do you wish to continue Mailed Date FI MAC Mailed Date cannot be before Error E336 Mailed Date can E336 Field from the Admin the date the request was not be before completion date Provider Request submitted of completion dates Results Page Mailed Date FI MAC Mailed Date cannot contain Error E042 Mailed Date E042 contains an Admin invalid characters contains a non numeric invalid character character or is not in M
302. e not to be included on the Medicare Cost Report 5 3 2 Outpatient All Other MSP LCC 13A The Outpatient All Other MSP LCC 13A report is a supplemental report to the Outpatient Cost Reimbursed 130 report The items reported on the Outpatient All Other MSP LCC 13A report are not to be included on the Medicare Cost Report 5 3 3 Outpatient Other MSP LCC 14A The Outpatient Other MSP LCC 14A report is a supplemental report to the Outpatient Other All Other Cost Reimbursed 140 report The items reported on the Outpatient Other MSP LCC 14A report are not to be included on the Medicare Cost Report 5 3 4 SNF Inpatient Part B MSP LCC 22A The SNF Inpatient Part B MSP LCC 22A report is a supplemental report to the SNF Inpatient Part B Cost Reimbursed 220 report The items reported on the SNF Inpatient Part B MSP LCC 22A report are not to be included on the Medicare Cost Report 5 3 5 SNF Outpatient MSP LCC 23A The SNF Outpatient MSP LCC 23A report is a supplemental report to the SNF Outpatient Cost Reimbursed 230 report The items reported on the SNF Outpatient MSP LCC 23A report are not to be included on the Medicare Cost Report 5 3 6 Home Health Part B MSP LCC 34A The Home Health Part B MSP LCC 34A report summarizes the Part B claims not under a plan of treatment that is subject to MSP LCC limitation Data in this report are subjec
303. e rolled up User Manual February 2009 Version No 2 0 Report Data B 99 Provider Statistical and Reimbursement System Report Type Data Element Description 329 TOTAL 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 TOTAL 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 TOTAL 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 TOTAL 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 TOTAL 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 TOTAL 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 TOTAL 0623 Displays by itself These fields are not populated on this report 329 TOTAL All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 FULL 0023 Does not display These fields are not populated on this report 329 FULL 027X All revenue code lines These fields are not populate
304. e to proceed E112 Primary Last Name field Provider Field must not be null Error E113 No primary Last Name entered Please enter a primary Last Name to proceed E113 Primary Phone field Provider Field must not be null Error E114 No primary Phone entered Please enter a primary phone number to proceed E114 Provider Field must be 10 digits Error E115 This is not a valid Primary phone number Please reenter a valid 10 digit phone number to proceed E115 Primary E mail field Provider Field must not be null Error E121 No primary E mail entered Please enter a Primary E mail address to proceed E121 Provider Field must contain the symbol Error E122 Please enter a valid primary e mail address E122 User Manual February 2009 Version No 2 0 Error Messages C 16 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message ID Primary Fax Provider If data is provided entry must Error E118 This is not a valid E118 field be 10 digits primary Fax Please reenter a valid 10 digit fax number to proceed Secondary Phone Provider If data is provided entry must Error E124 This is not a valid E124 field be 10 digits Secondary phone number Please reenter a valid 10 digit phone number to proce
305. ecessary services Organizationally each intermediary has a component responsible for the detection development and referral of fraud and abuse cases to the OIFO FI MAC Fiscal Intermediary Medicare Administrative Contractor Fiscal Intermediary Standard System FISS The data source for the PS amp R System Paid Claims are transmitted to the CMS Data Center once they are paid finalized in the FISS FISS processing is supported by up to eight 8 Medicare Data Centers nationwide for Fiscal Intermediaries and Medicare Administrative Contractors Fiscal Year FY Year long period used for budgeting The federal fiscal year begins October 1 and ends September 30 FSP Federal Specific Portion HCPCS HCFA Common Procedure Coding System A uniform method for providers and suppliers to report professional services procedures and supplies HCPCS includes CPT codes Level I national alpha numeric codes Level II and local codes Level IIl assigned and maintained by local Medicare carriers Health Insurance Claim HIC Number The unique alpha numeric Medicare entitlement number assigned to a Medicare beneficiary that appears on the Medicare card The HIC number is a unique identifier for each Medicare beneficiary The majority of the time it consists of a Social Security or Railroad Retirement Board RRB account number plus a Beneficiary Identification Code BIC User Manual Fe
306. ect the service type to include in the report By Service Type User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 9 Provider Statistical and Reimbursement System Field Exclude 329 and 339 Patient CBSA Visit Section Include 110 DRG Section Include 1000 Report By Report Group Exclude 329 and 339 Patient CBSA Visit Section Include 110 DRG Section Include 1000 Report By Report Type Exclude 329 and 339 Patient CBSA Visit Section Include 110 DRG Section Definition Optional Select the check box to exclude the 329 and 339 Patient CBSA visit section Optional Select the check box to include the DRG section for the reports in the request I nclude 110 DRG Section is only valid if By Service Type is AII or Inpatient Optional Select the check box to include the Consolidated Summary of All Report Types Report 1000 with the request Required if neither By Service Type nor By Report Type is selected Select the By Report Group option and then select the report group to generate Once a report group is highlighted click the 55 button to select the report group Once a report group is selected highlight the report group from the list of selected report groups and click the lt lt button to remove the report group To locate a report group in the list of report groups type the desired report group in the Search text box to scroll to the report group based on th
307. ected Select Load Date CMS Field must not be null Error E042 Load Date s E042 From FI MAC entry contains a non numeric Admin character or is not in MM DD YYYY format Select Load Date CMS Only numeric characters Error E042 Load Date s E042 From FI MAC entry contains a non numeric Admin character or is not in MM DD YYYY format Select Load Date CMS Entry must be in MM DD YYYY Error E042 Load Date s E042 From FI MAC format entry contains a non numeric Admin character or is not in MM DD YYYY format Select Load Date CMS Month Day and Year values Error E001 Load Date s E001 From FI MAC must be valid entry contains an invalid Admin month day and or year Select Load Date CMS Entry must be less than or Error E312 Load Dates do E312 From FI MAC equal to corresponding Load not have a valid date range Admin Date To date From from date To to dates Select Load Date CMS Field must not be null Error E042 Load Date s E042 To FI MAC entry contains a non numeric Admin character or is not in MM DD YYYY format Select Load Date CMS Only numeric characters Error E042 Load Date s E042 To FI MAC entry contains a non numeric Admin character or is not in MM DD YYYY format Select Load Date CMS Entry must be in MM DD YYYY Error E042 Load Date s E042 To FI MAC format entry contains a non numeric Admin character or is not in MM DD YYYY format User Manual February 2009 Ver
308. ed Secondary Provider If data is provided entry must Error E130 Please enter a E130 E mail field contain the symbol valid secondary e mail address Secondary Fax Provider If data is provided entry must Error E127 This is not a valid E127 field be 10 digits secondary Fax Please reenter a valid 10 digit fax number to proceed Reason for FI MAC Field must not be null Error E325 No Primary E325 Request field Non Reason For Request entered Admin Please enter Primary Reason For Request to proceed Incorrect Output All When the incorrect output Error E169 Output Format is E169 Format Selected format is selected not PDF or CSV C 11 Detail Report Request Report Request Confirmation The Detail Report Request Report Request Confirmation page error messages are presented in the following table Exhibit C 11 Detail Report Request Report Request Confirmation Page Error Messages Form Field User Type Validation Error Message ID Your Request All The Your Request Name Error E047 Your Request E047 Name Field field cannot be null Name is not entered Please enter a request name to proceed All This field must not contain Error E152 Request Name E152 special characters V can not contain special lt gt characters V Exclude CMS At least one provider s Error E311 At least one E311
309. ed The additional information section shows claim interest MSA E CBSA and claim report splits The report template also provides a monthly totals section that sums the information from the sections above An example of the outpatient 81x 82x Hospice Summary report template and the outpatient 81x 82x Hospice Payment Reconciliation detail report template follow User Manual Outpatient Reports February 2009 Version No 2 0 5 47 Provider Statistical and Reimbursement System Exhibit 5 26 Outpatient 81x 82x Hospice Summary Report Template Program iD REDESIGN Paid Dates 01 01 04 THRU 10 01 06 Report Run Date 02 01 07 Provider FYE 12 31 Provider Number T01515 BIRD SONG HOSPICE STATISTIC SECTION MEDICARE DAYS CLAIMS TOTAL UNDUPLICATED CENSUS COUNT CHARGE SECTION REVCODE DESCRIPTION HOSPICE RTN HOME HOSPICE CTNS HOME HOSPICE IP RESPITE HOSPICE IP NON RESPITE HOSPICE PHYSICIAN TOTAL COVERED CHARGES REIMBURSEMENT SECTION GROSS REIMBURSEMENT LESS DEDUCTIBLES COINSURANCE NET MSP PAYMENTS MSP RECONCILIATION OTHER ADJUSTMENTS NET REIMBURSEMENT ADDITIONAL INFORMATION SECTION CLAIM INTEREST PAYMENTS Feb 1 2007 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM SERVICES FOR PERIOD 01 01 04 03 31 04 UNDUP HOURS UNITS CHARGES UNDUP HOURS UNITS CHARGES UNDUP HOURS UNITS CHARGES DAYS DAYS DAYS DAYS 0 107 14 54 6 22224 13 039 1 525 538 96 0 0 0 0 00 11 301 84 757 21 690 56 0 0 0 0 00 0
310. ed units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 122 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 122 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 122 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 122 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 122 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 122 COINSURANCE The actual coinsurance amount from the paid claim record 122 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 122 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 122 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 132 CLAI MS Currently this field has no cost report usage 132 UNITS The number of u
311. edical condition symptom or complaint that is the basis for rendering a specific service s This coding system consists of three to five digit numeric or alpha numeric codes for reporting purposes Jurisdiction The territory subject matter or persons as determined by statute or constitution responsibility over which lawful authority may be exercised by a court or other justice agency LTHC Long Term Health Care Maximum Allowable Charge The maximum allowable cost for prescription drugs under Medicaid Medicaid Health care program cooperatively administered by federal and state governments to provide medical assistance to eligible needy individuals State programs of public assistance to persons regardless of age whose income and resources are insufficient to pay for health care Title XIX of the federal Social Security Act provides matching federal funds for financing state Medicaid programs effective January 1 1966 Medically Necessary Services or supplies that meet the following 1 they are appropriate and necessary for the symptoms diagnosis or treatment of the medical condition 2 they are provided for the diagnosis or direct care and treatment of medical conditions 3 they meet the standards of good medical practice within the medical community in the service area 4 they are not primarily for the convenience of the patient or provider 5 they are the most appropriate level or supply of service that c
312. edicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 82A OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports User Manual February 2009 Version No 2 0 Report Data B 93 Provider Statistical and Reimbursement System Report Type Data Element Description 82A NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 82A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 322 COUNT This is the total number of Requests for Advance Payment RAP for Part B 322 REI MB This is the total RAP payment amount for Part B 322 TOTAL INI TIAL RAP This is the initial Request for Advance Payment RAP submitted by the HHA for Part B 322 RAP CANCELLED BY CLAIM This is a claim cancel normally part of a claim adjustment for Part B 322 RAP AUTO CANCELLED This is the initial RAP cancel which is made when the final RAP is processed for Part B 322 RAP PROVIDER CANCELLED This is a RAP cancel initiated by the HHA for Part B 322 R
313. educt 2 00 Claim interest 000 Blood Deduct 5 00 Coins 5 00 MSP 2 00 Psyc Rad Matin po 12 39 54 PM Page 1 Report OD44202 Report Type 135 Paid Dates 01 01 04 to 10 01 06 User Manual February 2009 Version No 2 0 Outpatient Reports 5 31 Provider Statistical and Reimbursement System Exhibit 5 16 Outpatient xx5 Fee Reimbursed Payment Reconciliation Detail Report Template Last Page PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Service Month End N A OUTPATIENT FEE REIMBURSED Report Run Date 02 07 07 Provider FYE 12 31 Provider Number T00073 CROSS YOUR HEART HOSPITAL Service Period and Report Type Totals Service Period 01 01 2004 01 01 2006 Gross Cash Blood Line item Units Charges T Coins M Pac Red pon OTA 2 701 64 12255 000 200 200 200 512255 Report Type 135 Totals for CROSS YOUR HEART HOSPITAL Gross Cash Blood Line item Units Charges t t ins M Pac Red po 70164 512255 000 200 500 sogo 020 512255 Feb 7 2007 3 Page 2 Report 0044202 Report Type 135 Paid Dates 01 01 04 to 10 01 05 Reimbursements Gross Remb 12255 Less Cash Deduct 0 00 Blood Deduct 0 00 Coins 0 00 MSP 020 Psyc Red Net Raimb 512255 Reimbursements Gross Remb LESS Cash Deduct Blood Deduct Coins MS Psyc Red Net Remb 512255 0 00 0 00 0 00 0 00 0 00 212255 The rep
314. eductible amount from the paid claim record 730 COINSURANCE The actual coinsurance amount from the paid claim record 730 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 730 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 730 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 740 CLAI MS Currently this field has no cost report usage 740 UNITS The number of units applicable to each revenue code 740 CHARGES The charges applicable to each revenue code 740 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes User Manual February 2009 Version No 2 0 Report Data B 76 Provider Statistical and Reimbursement System Report Type Data Element Description 740 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4
315. eimbursed 222 SNF Inpatient Vaccine Outpatient SNF 5000 6499 Yes Part B 10096 Reasonable Cost 225 SNF Inpatient Fee Outpatient SNF 5000 6499 No Reimbursed 23A SNF Outpatient MSP LCC Outpatient SNF 5000 6499 No 23P SNF Outpatient OPPS Outpatient SNF 5000 6499 Yes 23Z SNF Ambulance Blend Outpatient SNF 5000 6499 Yes Effective 04 01 02 230 SNF Outpatient Cost Outpatient SNF 5000 6499 Yes Reimbursed 232 SNF Outpatient Vaccine Outpatient SNF 5000 6499 Yes Part B 10096 Reasonable Cost 235 SNF Outpatient Fee Outpatient SNF 5000 6499 No Reimbursed 24P SNF Outpatient OPPS Outpatient SNF 5000 6499 Yes 32M Home Health PPS MSP LCC Outpatient HHA 3100 3199 Yes 7000 8499 9000 9799 322 Home Health PPS Part B RAP Outpatient HHA 3100 3199 No 7000 8499 9000 9799 329 Home Health PPS Part B Outpatient HHA 3100 3199 Yes Episodes 7000 8499 9000 9799 33M Home Health PPS Part A Outpatient HHA 3100 3199 Yes MSP LCC 7000 8499 9000 9799 User Manual February 2009 Version No 2 0 Report Details A 7 Provider Statistical and Reimbursement System Report Service Provider Provider Cost Report Type Report Name Category Type s Number Range Yes No 332 Home Health PPS Part A RAP Outpatient HHA 3100 3199 No 7000 8499 9000 9799 339 Home Health PPS Part A Outpatient HHA 3100 3199 Yes Episodes 7000 8499 9000 9
316. ekly pass through payments lump sums and financial adjustments etc 23A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 34A CLAIMS Currently this field has no cost report usage 34A UNITS The number of units applicable to each revenue code 34A CHARGES The charges applicable to each revenue code 34A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 34A DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 34A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 34A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 34A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record User Manual February 2009 Version No 2 0 Report Data B 39 Provider Statistical and Reimbursement System Report Type Data Element Description 34A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 34A COINSURANCE The actual coinsurance amount from
317. eld User Type Validation Error Message ID Include 110 DRG All If the box is checked service Error E066 The DRG Section E066 Section type selected must be All or is only valid with selections of Inpatient Report Group All Inpatient 11x or must be 11x or Report Type 1107 must be 110 The 329 and 339 Box checked None of the The 329 and 339 Patient E320 Patient CBSA Visit providers in the request is an CBSA Visit Section is only Section HHA Provider two ways to applicable to HHA Providers determine if there is an HHA and reports 329 and 339 provider in the request a in the report type box a 32x 33x or 34x report is included or b HHA Provider is in the Xx3100 xx3199 xx7000 xx8499 xx9000 xx9799 range The 329 and 339 Box Checked At least one The 329 and 339 Patient E321 Patient CBSA Visit Section provider is an HHA Provider but the request is not Outpatient or All By Service Type OR 32x 33x xx9 By Report Group OR 329 339 By Report Type CBSA Visit Section is only applicable to HHA Providers and reports 329 and 339 C 4 Summary Report Request Select Service Period s The Summary Report Request Select Service Period s page error and warning messages are presented in the following table Exhibit C 4 Summary Report Request Select Service Period s Page Error and Warning Messa
318. elds are not populated on this report 329 FULL AII other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 LUPA 0023 Does not display These fields are not populated on this report 329 LUPA 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 LUPA 0274 Displays by itself These fields are not populated on this report 329 LUPA 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 LUPA 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 LUPA 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 LUPA 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 LUPA 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 107 Provider Statistical and Reimbursement System Report Type Data Element Description 329 LUPA 056X All reven
319. elected Error E214 Error retrieving E214 providers Providers amp arg1 System Error PS amp R Error while preparing to find Error E215 Error preparing to E215 the provider FYEs find Provider FYEs amp arg1 System Error PS amp R Error retrieving the provider Error E216 Error retrieving E216 FYEs Providers FYEs amp arg1 System Error PS amp R Error while preparing to find Error E217 Error preparing to E217 the providers by parent find providers by parent amp arg1 System Error PS amp R Error retrieving the providers Error E218 Error retrieving E218 by parent providers by parent amp arg1 System Error PS amp R Error while preparing to find Error E219 Error preparing to E219 child by provider find child by provider amp arg1 System Error PS amp R Error retrieving the child by Error E220 Error retrieving child E220 provider by provider amp arg1 System Error PS amp R Error while preparing to load Error E221 Error preparing to E221 the provider ranges load Provider ranges amp arg1 System Error PS amp R Error retrieving the provider Error E222 Error retrieving E222 ranges Provider ranges amp arg1 System Error PS amp R Error while preparing to find Error E223 Error preparing to E223 providers for Fl by type find providers for FI by type amp arg1 User Manual February 2009 Version No 2 0 Error Messages C 26 Provider Statistical and Reimbursement System
320. electing the From and To dates for each of the four periods and applying the date ranges to all providers or by specifying the From and To dates for all periods and providers The following table contains a description of each field on the page Field Definition Update Service Dates by Interval Interval Optional Select the interval year quarter or month to use for the From and To date ranges for each of the four reporting periods If interval and start dates are not applied the report is generated using the default dates populated when you accessed the page User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 11 Provider Statistical and Reimbursement System Field Definition Period 1 Start Date Optional Type the start date in MM DD YYYY format for the first reporting period or click the calendar icon to select the start date using the calendar Scroll through the months and select the date to use Click Apply to apply the dates to all providers for the From and To dates for each of the four reporting periods If interval and start dates are not applied the report is generated using the default dates populated when you accessed the page Update Service Dates by Period Period n From Optional Type the start date in MM DD YYYY format for each of the four reporting periods to assign the reporting period range individually or click the calendar icon to select the start date using
321. em Report Type Data Element Description 24P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 24P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 34P CLAIMS Currently this field has no cost report usage 34P UNITS The number of units applicable to each revenue code 34P CHARGES The charges applicable to each revenue code 34P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 34P DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 34P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 34P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 34P OUTLIER The outlier portion of the OPPS payment for the APC 34P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 34P CASH DEDUCTIBLE The actual cash deductible amount from the
322. ent Value Code 19 amount shown on the PS amp R are estimated payments made on a bill by bill basis by the PPS Pricer program For cost reporting purposes the amount must be recomputed 11S NEW TECHNOLOGY Summarizes new technology payments Value code 77 made under the Prospective Payment System 11S IPF ECT Summarizes IPF ECT Inpatient Psych Facility Electro Convulsive Therapy payments made under the Prospective Payment System 11S TOTAL OPERATING PAYMENTS This is the sum of the operating amounts for HSP FSP outlier DSH LI P IME teaching adjustment new technology IPF ECT and exception payments 11S HOSPITAL SPECIFIC This is the hospital specific portion of the PPS payment for capital The field will be zero for providers paid based on the hold harmless old capital or the hold harmless 100 percent federal method and for new hospitals during their first two years of operation 11S FEDERAL SPECIFIC This field includes the federal portion of the PPS payment for capital This field will also include the new capital amount for hospitals paid under the hold harmless old capital method 11S OUTLIER This field will show the outlier portion of the PPS payment for capital 11S HOLD HARMLESS This field shows the hold harmless amount paid for old capital based on the hold harmless old capital method 11S DSH This is the disproportionate share portion of the PPS capita
323. ent Description 145 CHARGES The charges applicable to each revenue code 145 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 145 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 145 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 145 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 145 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 145 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 145 COINSURANCE The actual coinsurance amount from the paid claim record 145 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 145 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 145 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the
324. enue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 SCIC 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 SCIC 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 SCIC 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 SCIC 0623 Displays by itself These fields are not populated on this report 339 SCIC All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 339 TOTAL 0023 Does not display These fields are not populated on this report 339 TOTAL 027X All revenue code lines Total Part B Med Supplies charges where the first three positions 027 excluding 0274 are rolled up 339 TOTAL 0274 Displays by itself Total Part B Prosthetics and Orthotics charges without outlier 339 TOTAL 029X All revenue codes lines Total Part B Durable Medical Equipment charges without where the first three positions 029 are rolled up outlier User Manual February 2009 Version No 2 0 Report Data B 132 Provider Statistical and Reimbursement System Report Type Data Eleme
325. eous Report Request page Your Request All This field must not contain Error E152 Request Name E152 Name special characters V can not contain special lt gt characters V Select Report CMS If the user selects PDF and Error E385 This request E385 Format FI MAC the page limit is over 500 exceeds the maximum pages allowable PDF file size Please select CSV or change request parameters Incorrect Output All When the incorrect output Error E169 Output Format is E169 Format Selected format is selected not PDF or CSV CG IS Detail Report Request Miscellaneous The Detail Report Request Miscellaneous page error messages are presented in the following table User Manual February 2009 Version No 2 0 Error Messages C 21 Provider Statistical and Reimbursement System Exhibit C 15 Detail Report Request Miscellaneous Page Error Messages Form Field User Type Validation Error Message ID Processing Error PS amp R While pages are processing a Error E100 Report request E100 user should not click the must start from the Back button in the Internet navigation bar Back button Explorer browser processing not allowed after submit is performed Application Down PS amp R Cognos ReportNet is down Error E014 Application E014 and therefore requesting down Not able to make reports is not possible
326. eport request is submitted and the Provider Statistical and Reimbursement Home page appears Reports generated from this page can be viewed by accessing the Detail Report Inbox option from the Report Inbox menu after the FI MAC Administrator has approved the request and the request has completed processing User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 23 Provider Statistical and Reimbursement System 3 5 Report Inbox Once a report request is submitted you can view the status of the request in the Reports Inbox by selecting the Summary Report Inbox or Detail Report Inbox option from the Report Inbox menu A report request is listed in the Summary Report Inbox as soon as the request has been submitted The summary request statuses are e Queued the request is queued for processing but has not begun processing e Processing the request has not completed processing e Complete the request has been submitted and has completed processing e Error the request contains technical problems and was not completed For detail report requests the Detail Report Inbox lists the status of the request The following statuses are available for detail requests e Queued the request is queued for processing but has not begun processing e Pending your FI MAC Administrator has not approved or declined the request e Processing your F MAC Administrator has approved the request and the request is being processed
327. equest status is Complete or Complete Modified You can delete summary reports and summary report requests from the Summary Report Inbox before 21 days has passed by clicking the Delete check box next to the corresponding reports report requests to delete and then clicking the Delete button at the bottom of the page to complete the delete process Detail report requests cannot be deleted from the Detail Report Inbox prior to the automatic 21 day period User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 28 Provider Statistical and Reimbursement System An example of the report request details page follows This page contains the details of the report request that displays if the request name hyperlink is selected CT S Provider Statistical amp Reimbursement System Site Map Announcements FAQ Help Logout FS GLOBAL FI 14000 User ID TRTEST17 Inbox Request Details Monday September 10 Home ReportInbox Request Report Detail Report Inbox Inbox Request Details Report Request TRTEST17 D 9904 Report Request ID TRTEST17 D 9904 2 Your Request Name TRTEST17 D 9904 Requested Provider s T00028 Requested Report s 110 115 118 119 11A 120 122 125 124 12P 12Z 130 132 135 13A 13P 13Z 140 142 145 144 14P 720 725 724 831 832 835 834 83P 83Z No Data Available T00028 115 118 119 120 122 125 124 12P 122 132 134 13Z 140 142 145 144 720 725 724
328. er 100007 PETERBORO GENERAL HOSPITAL Cam Bees se baa ved Om MOT NEN Patet Nec DCN Pint Carl d Med Rord d HIC Nume Recpt Dt Paid Ot Service From Service Thru BH Freq Trans Type Processor ID Patet Nan DCN Pont Cagri d Mead Rord HIC Num Paid Ot Service Frome Service Thru BH Freq Trass Type Processor ID Patet Na DCN Pint Creel d Med Rerd i HIC Nume Paid OF Service From Service Thru BH Freq Trans Type Processor ID Patet Name DCN Pint Cori amp Med Rcrd amp Feb 7 2007 BOSSK 20428010354705 001000009000 383000000009 1853904104 04 29 04 05 14 04 GAMBOA 04 18 04 FOFFM 901000002009 152000000000 1770656224 05 14 04 04 18 04 04 18 04 GUIDD 20478139554905 001000000000 336000002020 du HCPCS Units Charges GAPC 0450 99781 1 TOTAL Rav Code HOCS Units Charges GAPC 1 09 73 15 00 1 8100 73 15 000 PAYMENT RECONCILIATION REPORT OUTPATIENT OPPS 19 16 000 00 000 19 16 0 00 0 00 Ca sood MS Pac Deduct geduet C9 MSP Recon Rad 0450 99781 181 00 73 15 00 19 16 0 00 00 TOTAL 8100 7315 000 008 19 16 0 00 0 00 Rev Ca Sood Cod HCPCS Units Charges GAPC D D Coins MSP 0324 71000 1 195 00 41 69 000 0 00 20 84 000 0 99 0450 99784 1 952 00 221 60 000 6 09 5300 000 000 0730 93005 1 1S000 19 78 0 00 000 3 95 000 000 TOTAL 3 1 337 09 28307 000 000 7780 000 000
329. er Range Cost Report Yes No 130 Outpatient Cost Reimbursed Outpatient Either Hospital or ESRD 0001 0999 1200 1399 2000 2299 2300 2899 2900 2999 3025 3099 3300 3399 3500 3799 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 132 Outpatient Part B Vaccine Outpatient Either Hospital or ESRD 0001 0999 1200 1399 2000 2299 2300 2899 2900 2999 3025 3099 3300 3399 3500 3799 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 135 Outpatient Fee Reimbursed Outpatient Either Hospital or ESRD 0001 0999 1200 1399 2000 2299 2300 2899 2900 2999 3025 3099 3300 3399 3500 3799 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 No 14A Outpatient Other MSP LCC Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 TO00 T999 M300 M399 R300 R399 No User Manual February 2009 Version No 2 0 Report Details A 5 Provider Statistical and Reimbursement System Report Type Report Name Service Category Provider Type s Provider Number Range Cost Report Yes No 14P Outpatient Other OPPS Outpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 TO00 T999 M300 M399 R300 R399 Yes 140 Outpatient Other All Other Cost Reimbursed Outpatient Hospital Group 0001 0999
330. er received to replace a medical device that may have been defective or under warranty This amount can be identified with a value code of FD on the claim 11K CASH DEDUCTIBLE The sum of actual cash deductible amount from the paid claim records 11K BLOOD DEDUCTIBLE The sum of actual blood deductible amount from the paid claim records 11K COI NSURANCE The sum of actual coinsurance amount from the paid claim records 11K NET MSP PAYMENTS The sum of net payments made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 11K MSP PASS THRU RECONCILIATION This field is informational only and should not be included in the cost report This amount occurs in cases where Medicare has made no payment on the claim yet classifies it as PR Partial Recovery because of the estimated pass through payments The actual pass through amounts will be determined in the cost report The MSP Pass Thru Reconciliation amount must be ignored for cost reporting 11K OTHER ADJ USTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 11K NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments
331. erated in this request User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 17 Provider Statistical and Reimbursement System 5 Click Continue to continue to the next page to specify the service periods and claim paid dates to include in the report s or click Back to return to the previous page The following page appears if you click Continue Cs Provider Statistical amp Reimbursement System Site MAP Annaun cement BAO MTS NN GLOBAL FI MAC 14000 Sar MEE UU Detail Report Request Thursday August 23 Home Report Inbox Request Report Favorite Requests Request Summary Request Detail Detail Report Request 3 Select Service Periods Note Period 1 From and To dates are required Format MM DD YYYY Update Service Dates by Interval Interval Year Period 1 Start Date l Esj Apply Update Service Dates by Period Period 1 Period 2 Period 3 Period 4 From E From Es From E From Es Apply To E To Eg To E To Eg Update Service Dates by Provider s Provider ID Period 1 Period 2 Period 3 Period 4 T01301 From Eg From E From E From Eg FYE 0630 ro T E m 8 4 Select Paid Dates From 0170172006 FF To 1070172006 rs Back Continue 6 Select the service periods and claim paid dates to include in the report s You can specify the service period by selectin
332. erating payments made to a specific provider 11K DRG WEIGHT FRACTION DISCHARGES This field reflects the DRG weight times the discharge fraction divided by the discharges This amount can be used to calculate a transfer adjusted case mix 11R DISCHARGES This field is only valid for inpatient claims This indicates the number of patients discharged 11R MEDICARE DAYS The provider s hospital routine adults and peds days Note The provider s crosswalk may be used to allocate days for cost reporting purposes 11R CLAIMS Currently this field has no cost report usage User Manual February 2009 Version No 2 0 Report Data B 14 Provider Statistical and Reimbursement System Report Type Data Element Description 11R UNITS The number of units applicable to each revenue code Note for accommodations revenue codes this may include non covered days 11R CHARGES The charges applicable to each revenue code 11R REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 11R DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 11R TOTAL ACCOMODATI ONS This category may include provider li
333. ere the first three positions 062 are rolled up 399 FULL 0623 Displays by itself Part B surgical dressings charges with outlier 399 FULL AII other Rev Codes display as All other Part B revenue code charges they come in on the claim they do not roll up 399 LUPA 0023 Does not display These fields are not populated on this report 399 LUPA 027X All revenue code lines Part B medical supplies charges with outlier where the first three positions 027 excluding 0274 are rolled up 399 LUPA 0274 Displays by itself Part B prosthetics and orthotics charges with outlier 399 LUPA 029X All revenue codes lines Part B durable medical equipment charges with outlier where the first three positions 029 are rolled up 399 LUPA 042X All revenue code lines Total physical therapy covered charges during LUPA episode where the first three positions 042 are rolled up 399 LUPA 043X All revenue code lines Total occupational therapy covered charges during LUPA where the first three positions 043 episode are rolled up 399 LUPA 044X All revenue code lines Total speech therapy covered charges during LUPA episode where the first three positions 044 are rolled up 399 LUPA 055X All revenue code lines Total covered charges related to nursing services during PEP where the first three positions 055 episode are rolled up 399 LUPA 056X All revenue code lines Total covered charges related to med soc serv during LUPA
334. ersion No 2 0 Error Messages C 29 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message Parent Provider no Parent If you are requesting a Warning Service dates longer has access to Provider report from when a parent requested do not coincide a provider provider owned a child with requestor access provider it must be in the rights for Provider ID range of when the Provider These dates will be owned the child modified on the Confirm Report Request screen to reflect valid access dates Do you wish to Continue E001 Change Periods with All All date fields Month Day Error E001 Service Specific Dates Apply and Year values must be Date s entry contains an button valid invalid month day and or year E001 Interval Apply All The date field s Month Day Error E001 Period 1 Button and Year values must be Start Date contains an valid invalid month day and or year E001 Paid Date From Date All Month Day and Year values Error E001 Paid Date s must be valid entry contains an invalid month day and or year E001 Paid Date To Date All Month Day and Year values Error E001 Paid Date s must be valid entry contains an invalid month day and or year E001 Select Paid From All Month Day and Year values Error E001 From Paid Date must be valid Date entry contains an invalid month day and or year
335. ervices provided by critical access hospitals reimbursed on a reasonable cost basis The items reported on the Critical Access Hospital Vaccines Part B 10096 Reasonable Cost 852 report are included on the Medicare Cost Report 5 7 xx5 Fee Reimbursed Report Template The xx5 Fee Reimbursed Provider Summary report template displays summary statistic charge reimbursement and additional information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The data displayed in each section is determined by the report selected for generation The statistic section shows the number of claims for each reporting period The charge section displays the number of units and the total dollar amount of the revenue code being reported The reimbursement section displays how net reimbursement is calculated Finally the additional information section displays the claim interest payments The xx5 Fee Reimbursed Payment Reconciliation detail report template is divided into claim information reimbursements and additional information sections The claim information section displays patient information such as the patient name DCN Line Item Reimbursement and the charges for the revenue codes The reimbursements section shows how net reimbursement is calculated The addition
336. ese fields are not populated on this report where the first three positions 060 are rolled up 329 SCIC PEP 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 SCIC PEP 0623 Displays by itself These fields are not populated on this report 329 SCIC PEP All other Rev Codes display These fields are not populated on this report as they come in on the claim they do not roll up 329 SCIC 0023 Does not display These fields are not populated on this report 329 SCIC 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 SCIC 0274 Displays by itself These fields are not populated on this report 329 SCIC 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 SCIC 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 SCIC 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 SCIC 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 SCIC 055X All revenue code lines These fields are not populated on this report where the f
337. est Report Favorite Requests Request Summary Request Detail Summary Report Request 1 Select Provider s Search T00006 HALF PIPE HOSPITAL SYSTEM T 0007 PETERBORO GENERAL HOSPITAL TO0026 MOUNTAIN TOP MEDICAL CENTER T 0028 PARROTHEAD MEDICAL CENTER T 0044 SACRED SISTERS MEDICAL CENTER 701301 SHATTERED HEART AT THE OAKS 701433 MISS DAISYS COMMUNITY MENTAL HEAL 701514 PETERBORO HOSPICE 702300 SHATTERED HEART ESRD T 2581 INDIAN BEACH DIALYSIS CENTER zl Expand D Include Subunits Continue 2 Select the provider s for which to generate a report The following table contains a description of each field on the page Field Definition Providers Required Select the providers to include in the report request If a provider is listed in red text the FI MAC no longer services the provider but can generate reports for the time period of its ownership Once a provider number is highlighted click the 55 button to select the provider number Once a provider number is selected highlight the provider number from the list of selected provider numbers and click the button to remove the provider number To locate a provider number in the list of providers type the desired provider number in the Search text box to scroll to the provider number based on the entered criteria User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 8 Provider Statistic
338. evenue code lines Total Part B nursing count where the first three positions 055 are rolled up 399 TOTAL 056X All revenue code lines Total Part B medical social services where the first three positions 056 are rolled up User Manual February 2009 Version No 2 0 Report Data B 158 Provider Statistical and Reimbursement System Report Type Data Element Description 399 TOTAL 057X All revenue code lines Total Part B home health aide count where the first three positions 057 are rolled up 399 TOTAL 058X All revenue code lines Total Part B other visits where the first three positions 058 are rolled up 399 TOTAL 059X All revenue code lines These fields are not normally used where the first three positions 059 are rolled up 399 TOTAL 060X All revenue code lines Total Part B oxygen charges where the first three positions 060 are rolled up 399 TOTAL 062X All revenue code lines Total Part B medical supplies charges where the first three positions 062 are rolled up 399 TOTAL 0623 Displays by itself Total Part B surgical dressings charges 399 TOTAL All other Rev Codes display as All other Part B revenue code charges they come in on the claim they do not roll up 399 FULL EPISODES WITHOUT OUTLIER Part B number of episodes without outlier for full episodes 399 FULL HIPPS REIMBURSEMENT
339. f Total Part B Surgical Dressings charges without outlier 339 TOTAL All other Rev Codes display as All other Part B Revenue Code Charges they come in on the claim they do not roll up 339 FULL EPISODES WITHOUT OUTLI ER Part B Medical Supplies charges with outlier 339 FULL HIPPS REIMBURSEMENT Part B HIPPS Reimbursement without outlier for full episodes WITHOUT OUTLIER 339 FULL EPISODES WITH OUTLIER Part B number of episodes with outlier for full episodes 339 FULL HIPPS REIMBURSEMENT WITH Part B HIPPS Reimbursement with outlier for full episodes OUTLIER 339 FULL OUTLIER REIMBURSEMENTS Part B outlier reimbursement for full episodes 339 FULL PROSTHETIC ORTHOTIC This is P amp O for full episodes DEVICES User Manual February 2009 Version No 2 0 Report Data B 133 Provider Statistical and Reimbursement System Report Type Data Element Description 339 FULL DME This is DME for full episodes 339 FULL OXYGEN This is oxygen for full episodes 339 FULL OTHER FEE REIMBURSEMENTS Part B other fee for full episodes 339 FULL GROSS REIMBURSEMENT Part B gross reimbursement for full episodes 339 FULL DEDUCTIBLES This is DED for Part B 339 FULL COINSURANCE This is coinsurance for Part B 339 FULL NET MSP PAYMENTS This is MSP for Part B 339 FULL MSP RECONCILIATION Net MSP for Part B 339 FULL OTHER ADJUSTMENT
340. fied p After 21 calendar days with a Status of Complete Complete Modified Declined or Error the report request will no longer appear in this inbox If the Status is Complete or Complete Modified it is your responsibility during these 21 days to save the reports to your own computer The inbox pages display the request name specified when the request was submitted the date of the request the report format the status of the report and the number of days the report remains in your inbox To save the report open the report by selecting the corresponding icon in the PDF column or CSV column and then selecting the desired save option based on the report format If the report format is PDF click Save a Copy or select the Save as menu option from the File menu If the report format is CSV click Save in the File Download dialog box If Separate Files by Provider is selected a ZIP file is created containing a separate file for each provider requested for both CSV and PDF requests For PDF reports the ZIP file can be saved or opened when the PDF icon is clicked For CSV reports when the user clicks the CSV icon a secondary page displays which when clicking on the links the user can save or open the ZIP file User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 26 Provider Statistical and Reimbursement System mm osoft Internet Explo
341. field Error E333 Favorite Name E333 Favorite must contain valid data if the is not entered Please enter a Checkbox selected Save Request as Favorite favorite name to proceed checkbox is selected Favorite Name All This field can only contain Error E334 Favorite Name E334 field alpha numeric characters and can only contain alpha the following special numeric characters and the characters _ following special characters Insufficient Room All Users may only save up to Warning W010 The number W010 in the Favorites 100 requests of Saved Favorites limit has Request s Inbox been reached This request will be submitted but not saved Do you wish to continue Favorite Name All The Favorite Name that was Warning W011 A Favorite W011 field entered already exists Request with this name already exists Its saved parameters will be lost Do you wish to continue User Manual February 2009 Version No 2 0 Error Messages C 10 C 7 Provider Statistical and Reimbursement System Detail Report Request Select Provider s The Detail Report Request Select Provider s page error messages are presented in the following table Exhibit C 7 Detail Report Request Select Provider s Page Error Messages Form Field User Type Validation Error Message ID List Box 2 CMS Must contain at least one Error E025 No provider E025 Selected Items FI MAC provider number s
342. fields are not populated on this report where the first three positions 062 are rolled up 339 FULL 0623 Displays by itself These fields are not populated on this report 339 FULL All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 339 LUPA 0023 Does not display These fields are not populated on this report 339 LUPA 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 LUPA 0274 Displays by itself These fields are not populated on this report 339 LUPA 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 122 Provider Statistical and Reimbursement System Report Type Data Element Description 339 LUPA 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 LUPA 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 LUPA 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 LUPA 055X All revenue code
343. first three positions 029 are rolled up These fields are not populated on this report User Manual February 2009 Version No 2 0 Report Data B 118 Provider Statistical and Reimbursement System Report Type Data Element Description 339 SCIC PEP 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 SCIC PEP 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 SCIC PEP 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 SCIC PEP 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 SCIC PEP 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 SCIC PEP 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 SCIC PEP 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 SCIC PEP 059X All revenue code lines These fields are not populated on this report where th
344. flects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 11A 18A 21A 118 and all other inpatient reports are transferred to the cost report 11U CLAIM INTEREST PAYMENTS Sum of interest paid on claims due to untimely claims processing Currently this field has no cost report usage 11U IRF PENALTY AMOUNT The 2596 penalty assessed for failure to submit IRF PAI data timely 11U LTCH SHORT STAY OUTLIER PAYMENTS The per diem payments made under PPS to the provider for a patient s stay in the facility prior to being transferred to another facility These payments are included in the net reimbursement field This field is shown for informational purposes only User Manual February 2009 Version No 2 0 Report Data B 29 Provider Statistical and Reimbursement System Report Type Data Element Description 11U CAP FED SPECIFIC 10096 Note This field equals the federal specific field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period This field should be used by ho
345. for Request a H Back Continue 8 Select the report format radio button to specify the type of report format portable document format PDF or comma separated values CSV format Note if you select to generate a PDF file that results in an excessively large PDF file you will be prompted to change your reporting parameters or to select the CSV option If the CSV option is selected the report output is automatically generated as a ZIP file containing the report request Once the report format is selected type the contact information for the report output The following table contains a description of each field on the page Field Definition Output Report Format Required Select the report format radio button to specify the type of report format portable document format PDF comma separated values CSV format Note if you select to generate a PDF file that results in an excessively large PDF file you will be prompted to change your reporting parameters or to select the CSV option User Manual February 2009 Version No 2 0 Performing Tasks in the PS amp R 3 20 Provider Statistical and Reimbursement System Field Definition Primary First Name Required Type the first name of the primary contact for the report request Last Name Required Type the last name of the primary contact for the report request Phone Required Type the telephone number of the primary contact fo
346. for a complete listing and a description of all revenue codes 740 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 740 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 740 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 740 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 740 COINSURANCE The actual coinsurance amount from the paid claim record 740 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 740 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 740 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 750 CLAIMS Currently this field has no cost report usage 750 UNITS The number of units applicable to each revenue code 750 CHARGES The charges applicable to each revenue code 750 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue c
347. for a complete listing and a description of all revenue codes 81P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 81P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 81P OUTLIER The outlier portion of the OPPS payment for the APC 81P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 81P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 81P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 81P COINSURANCE The actual coinsurance amount from the paid claim record 81P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 81P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 81P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 81P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc
348. for the Load Error E260 Results do not exist E260 Control Release History for LCRIse History for User amp arg1 System Error PS amp R Cannot find the provider for Error E263 Provider doesn t exist E263 the specified key for key amp arg1 System Error PS amp R SQL Exception Occurred Error E264 SQLException E264 amp arg1 System Error PS amp R Cannot find the providers Error E265 No Providers found E265 for amp arg1 System Error PS amp R Cannot find the ownership Error E276 No Ownership Date E276 date found for amp arg1 System Error PS amp R End Date contains invalid Error E277 end date contains E277 numeric data invalid numeric data amp arg1 System Error PS amp R Start Date contains invalid Error E278 start date contains E278 numeric data invalid numeric data amp arg1 System Error PS amp R Cannot find the report Error E289 No Report found for E289 amp arg1 System Error PS amp R Error in CreateParms Method Error E290 create parms failed E290 due to amp arg1 System Error PS amp R No results found for the Error E293 Results do not exist E293 specified user for user amp arg1 System Error PS amp R Parameter OP describing the Error E297 The operation was E297 Operation to be performed not set please set the op has to be set parameter in the form System Error PS amp R Define the Operation before Error E298 The operation amp arg1 E298 using it has not been defined System Error PS am
349. g 0274 are rolled up 399 LUPA 0274 Displays by itself Part B Prosthetics and Orthotics charges 399 LUPA 029X All revenue codes lines Part B Durable Med Equip charges where the first three positions 029 are rolled up 399 LUPA 042X All revenue code lines Total physical therapy covered charges during LUPA episode where the first three positions 042 are rolled up 399 LUPA 043X All revenue code lines Total occupational therapy covered charges during LUPA where the first three positions 043 episode are rolled up 399 LUPA 044X All revenue code lines Total speech therapy covered charges during LUPA episode where the first three positions 044 are rolled up 399 LUPA 055X All revenue code lines Total covered charges related to nursing services during PEP where the first three positions 055 episode are rolled up 399 LUPA 056X All revenue code lines Total covered charges related to med soc serv during LUPA where the first three positions 056 are rolled up episode User Manual February 2009 Version No 2 0 Report Data B 154 Provider Statistical and Reimbursement System Report Type Data Element Description 399 LUPA 057X All revenue code lines Total covered charges related to home health aide serv during where the first three positions 057 LUPA episode are rolled up 399 LUPA 058X All revenue code lines Part B ot
350. g and a description of all revenue codes 745 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 745 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis User Manual February 2009 Version No 2 0 Report Data B 83 Provider Statistical and Reimbursement System Report Type Data Element Description 745 CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 745 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 745 COINSURANCE The actual coinsurance amount from the paid claim record 745 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 745 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 745 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 755 CLAIMS Currently this field has no cost report usage 755 UNITS The number of units applicable to each revenue code
351. g the interval and period start date and clicking the Apply button next to the Interval and Start Date fields to apply these date ranges to all providers and periods by selecting the from and to dates for each of the four periods and clicking the Apply button next to the from and to date fields for each of the four periods to apply the date ranges to all providers or by specifying the from and to dates for all periods and providers The following table contains a description of each field on the page Field Definition Update Service Dates by Interval Interval Optional Select the interval year quarter or month from the drop down list to use for the from and to date ranges for each of the four reporting periods If interval and start dates are not applied the report is generated using the default dates populated when you accessed the page User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 18 Provider Statistical and Reimbursement System Field Period 1 Start Date Period n From Period n To Provider ID From Provider ID5 To Paid Dates From Paid Dates To Exclude Definition Optional Type the start date in MM DD YYYY format for the first reporting period or click the calendar icon to select the start date using the calendar Scroll through the months and select the date to use Click Apply to apply the dates to all providers for the from and
352. ges Form Field User Type Validation Error Warning Message ID Update Service All Date field must not be null Error E322 Period 1 Start E322 Dates by Interval Date contains a non numeric character or is not in MM DD YYYY format All Date field must contain only Error E322 Period 1 Start E322 numeric characters Date contains a non numeric character or is not in MM DD YYYY format All Date field entry must be in Error E322 Period 1 Start E322 MM DD YYYY format Date contains a non numeric character or is not in MM DD YYYY format User Manual February 2009 Version No 2 0 Error Messages C 4 Provider Statistical and Reimbursement System Form Field User Type Validation Error Warning Message ID All The date field s Month Day Error E001 Period 1 Start E001 and Year values must be Date contains an invalid valid month day and or year Update Service All All date field entries must Error E069 Service E069 Dates by Period contain only numeric Date s entry contains a characters non numeric character or is not in MM DD YYYY format All All date field entries must Error E069 Service E069 be in MM DD YYYY format Date s entry contains a non numeric character or is not in MM DD YYYY format All All date fields Month Day Error E001 Service E001 and Year values must be Date s entry contains an valid invalid month day and or year
353. ges associated with revenue codes designated as ancillary 24P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 24P OUTLIER The outlier portion of the OPPS payment for the APC 24P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 24P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 24P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 24P COINSURANCE The actual coinsurance amount from the paid claim record 24P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 24P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 24P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 24P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 50 Provider Statistical and Reimbursement Syst
354. gh payments lump sums and financial adjustments etc 725 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 72A CLAI MS Currently this field has no cost report usage 72A UNITS The number of units applicable to each revenue code 72A CHARGES The charges applicable to each revenue code 72A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 72A DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 72A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 72A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 72A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 72A COI NSURANCE The actual coinsurance amount from the paid claim record 72A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance User Manual February 2009 Version No 2 0 Report Data B 89 Prov
355. h Agency Payment Reconciliation detail report template displays detail claim information reimbursements and additional information sections The claim information section contains data such as the number of Part A Part B visits fee type HCPCS and charges for each revenue code The reimbursements section shows how net reimbursement is calculated The additional information section contains data such as deductibles HIPPS code HIPPS weight payment type and cancel method There is a monthly totals section at the bottom of the report which sums the information from the sections above An example of the outpatient 322 332 Home Health Agency Summary report template and the outpatient 322 332 Home Health Agency Payment Reconciliation detail report template follow User Manual Outpatient Reports February 2009 Version No 2 0 5 44 Provider Statistical and Reimbursement System Exhibit 5 24 Outpatient 322 332 Home Health Agency Summary Report Template Program ID REDESIGN Paid Dates 01 01 04 THRU 10 01 06 Report Run Date 02 05 07 Provider FYE 12 31 Provider Number 137008 MOBILE NURSE SERVICES TOTAL INITIAL RAP RAP CANCELLED BY CLAIM RAP AUTO CANCELLED RAP PROVIDER CANCELLED RAP Fi CANCELLED TOTAL CANCELLED RAPS TOT RAPS OUTSTANDING GROSS REIMBURSEMENT NET REIMBURSEMENT Feb 5 2007 COUNT 27 1 1 403 ICES FOR PERIOD 01 01 04 12 31 04 52 489 27 0 00 2 815 90 0 00 0 00 2 816
356. he results Do you wish to continue Freestanding Entry is one day greater Warning W004 You have W004 Providers Only than previous Service Period To Date this checks to see if the service periods are consecutive selected non consecutive service periods This will exclude cost report data from the results Do you wish to continue User Manual February 2009 Version No 2 0 Error Messages C 6 Provider Statistical and Reimbursement System Form Field User Type Validation Error Warning Message ID All Field must not be null Error E038 Service E038 Date s entry for Provider ID 5 contains a non numeric character or is not in MM DD YYYY format Service Period To AII Only numeric characters Error E038 Service E038 Dates in Update Date s entry for Provider Service Dates by ID 5 contains a non Provider s numeric character or is not in MM DD YYYY format All Entry must be in Error E038 Service E038 MM DD YYYY format Date s entry for Provider ID contains a non numeric character or is not in MM DD YYYY format All Month Day and Year Error E001 Service E001 values must be valid Date s entry for Provider ID contains an invalid month day and or year All Entry must be greater than Error E312 Service dates E312 or equal to corresponding for Provider ID do not Service Period From Date have a valid date range
357. he Part A information OUTLIER 339 PEP OUTLIER REIMBURSEMENTS This is THE Part A information User Manual February 2009 Version No 2 0 Report Data B 134 Provider Statistical and Reimbursement System Report Type Data Element Description 339 PEP PROSTHETIC ORTHOTIC DEVICES This is the Part A information 339 PEP DME This is the Part A information 339 PEP OXYGEN This is the Part A information 339 PEP OTHER FEE REIMBURSEMENTS This is the Part A information 339 PEP GROSS REIMBURSEMENT This is the Part A information 339 PEP DEDUCTIBLES This is the Part A information 339 PEP COINSURANCE This is the Part A information 339 PEP NET MSP PAYMENTS This is the Part A information 339 PEP MSP RECONCILIATION This is the Part A information 339 PEP OTHER ADJUSTMENTS This is the Part A information 339 PEP NET REIMBURSEMENT This is the Part A information 339 PEP CLAIM INTEREST PAYMENTS This is the Part A information 339 SCIC PEP EPISODES WITHOUT This is the Part A information OUTLIER 339 SCIC PEP HIPPS REIMBURSEMENT This is the Part A information WITHOUT OUTLIER 339 SCIC PEP EPISODES WITH OUTLIER This is the Part A information 339 SCIC PEP HIPPS REIMBURSEMENT This is the Part A information WITH OUTLIER 339 SCIC PEP OUTLIER REIMBURSEMENTS This is the Part A information 339 SCIC PEP PROSTHETI C ORTHOTI C This is the P
358. he default value is the earliest date in the paid cycle date from the paid claims file loaded for the selected providers Click the radio button and type the start date in MM DD YYYY format for the paid date range to include in the report or click the calendar icon to select the start date to use in the paid date range using the calendar Scroll through the months and select the date to use Note that only dates later than the default date can be selected User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 12 Provider Statistical and Reimbursement System Field Definition Paid Dates To Required if the I nclude all Paid Dates at the time of report generation option is not selected The default value is the latest paid cycle date from the paid claim files loaded for the FI MAC Type the end date in MM DD YYYY format for the paid date range to include in the report or click the calendar icon to select the end date to use in the paid date range using the calendar Scroll through the months and select the date to use Note that only dates before the default date can be selected 7 Click Continue to continue to the next page to specify the report format or click Back to return to the previous page Click Reset to restore the values on the page to the default values The following page appears if you click Continue Cs Provider Statistical amp Reimbursement System Site Map Announcements
359. he per discharge exception interim payment for capital related costs that qualifying hospitals are entitled to receive in accordance with Medicare payment policy 11V TOTAL CAPITAL PAYMENTS This is the sum of the capital amounts for HSP FSP outlier hold harmless disproportionate share adjustment indirect medical education and exception payments 11V GROSS REIMBURSEMENT This amount is the sum of total operating and total capital payments 11V DEVICE CREDIT This amount represents the credit that a provider received to replace a medical device that may have been defective or under warranty This amount can be identified with a value code of FD on the claim User Manual February 2009 Version No 2 0 Report Data B 31 Provider Statistical and Reimbursement System Report Type Data Element Description 11V CASH DEDUCTIBLE The sum of actual cash deductible amount from the paid claim records 11V BLOOD DEDUCTIBLE The sum of actual blood deductible amount from the paid claim records 11V COINSURANCE The sum of actual coinsurance amount from the paid claim records 11V NET MSP PAYMENTS The sum of net payments made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 11V MSP PASS THRU RECONCILIATI ON This field is
360. he units paid per RUG category 180 PB2 This field reflects the units paid per RUG category 180 PB1 This field reflects the units paid per RUG category 180 PA2 This field reflects the units paid per RUG category 180 PA1 This field reflects the units paid per RUG category 180 AAA This field reflects the units paid per RUG category 12A CLAIMS Currently this field has no cost report usage 12A UNITS The number of units applicable to each revenue code 12A CHARGES The charges applicable to each revenue code 12A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 12A DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 12A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 12A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 12A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 12A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 12A COINSURANCE The actual coinsurance amount from the paid claim record 12A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payment
361. hensive Outpatient Rehabilitation Facilities MSP LCC 75A report are not to be included on the Medicare Cost Report 5 3 11 Community Mental Health Center MSP LCC 76A The Community Mental Health Center MSP LCC 76A report is a supplemental report to the Community Mental Health Center 760 report The items reported on the Community Mental Health Center MSP LCC 76A report are not to be included on the Medicare Cost Report 5 3 12 ASC and ASC Fee Schedule MSP LCC 83A The ASC and ASC Fee Schedule MSP LCC 83A report is a supplemental report to the ASC and ASC Fee Schedule After 12 90 831 report The items reported on the ASC and ASC Fee Schedule MSP LCC 83A report are not to be included on the Medicare Cost Report 5 3 13 Critical Access Hospital MSP LCC 85A The Critical Access Hospital MSP LCC 85A report is a supplemental report to the Critical Access Hospital 850 report The items reported on the Critical Access Hospital MSP LCC 85A report are not to be included on the Medicare Cost Report 5 4 XxP Outpatient Prospective Payment System OPPS Report Template The xxP Outpatient Prospective Payment System OPPS provider summary report template displays summary statistic charge reimbursement and additional information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods eve
362. her visits without outlier where the first three positions 058 are rolled up 399 LUPA 059X All revenue code lines Total visit covered charges for various disciplines for LUPA where the first three positions 059 episode are rolled up 399 LUPA 060X All revenue code lines Part B oxygen charges where the first three positions 060 are rolled up 399 LUPA 062X All revenue code lines Part B medical supplies charges where the first three positions 062 are rolled up 399 LUPA 0623 Displays by itself Part B surgical dressings charges 399 LUPA All other Rev Codes display as All other Part B revenue code charges they come in on the claim they do not roll up 399 PEP 0023 Does not display These fields are not populated on this report 399 PEP 027X All revenue code lines Part B Med Supplies charges where the first three positions 027 excluding 0274 are rolled up 399 PEP 0274 Displays by itself Part B prosthetics and orthotics charges 399 PEP 029X All revenue codes lines Part B durable medical equipment charges where the first three positions 029 are rolled up 399 PEP 042X All revenue code lines Total physical therapy covered charges during PEP episode where the first three positions 042 are rolled up 399 PEP 043X All revenue code lines Total occupational therapy covered charges during PEP where the first three positions 043 episode are rolled up 399 PEP 044X All revenue code lines To
363. here the first three positions 043 outlier are rolled up 399 FULL 044X All revenue code lines Occupational therapy visit count during full episode with where the first three positions 044 outlier are rolled up 399 FULL 055X All revenue code lines Visit count related to nursing services during full episode with where the first three positions 055 outlier are rolled up 399 FULL 056X All revenue code lines Visit count related to med soc serv during full episode without where the first three positions 056 are rolled up outlier User Manual February 2009 Version No 2 0 Report Data B 147 Provider Statistical and Reimbursement System Report Type Data Element Description 399 FULL 057X All revenue code lines Visit count related to home health aide serv during full episode where the first three positions 057 with outlier are rolled up 399 FULL 058X All revenue code lines Part B other visits where the first three positions 058 are rolled up 399 FULL 059X All revenue code lines Total visit count for various disciplines for full episode with where the first three positions 059 outlier are rolled up 399 FULL 060X All revenue code lines Part B oxygen charges with outlier where the first three positions 060 are rolled up 399 FULL 062X All revenue code lines Part B medical supplies charges with outlier wh
364. his field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 83P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 83P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 83P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 59 Provider Statistical and Reimbursement System Report Type Data Element Description 83P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 83P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 12Z CLAIMS Currently this field has no cost report usage 12Z UNITS The number of units applicable to each revenue code 12Z CHARGES The charges applicable to each revenue code 12Z GROSS FEE AMT This is an accumula
365. his is the Part B MSP LCC information Rev Code PDF Revenue Code CSV Column This is the Part B MSP LCC information User Manual February 2009 Version No 2 0 Report Data B 139 Provider Statistical and Reimbursement System Report Type Data Element Description 33M 0023 Does not display This is the Part A MSP LCC information 027X All revenue code lines where the first three positions 027 excluding 0274 are rolled up 0274 Displays by itself 029X All revenue code lines where the first three positions 029 are rolled up 042X All revenue code lines where the first three positions 042 are rolled up 043X All revenue code lines where the first three positions 043 are rolled up 044X All revenue code lines where the first three positions 044 are rolled up 055X All revenue code lines where the first three positions 055 are rolled up 056X All revenue code lines where the first three positions 056 are rolled up 057X All revenue code lines where the first three positions 057 are rolled up 058X All revenue code lines where the first three positions 058 are rolled up 059X All revenue code lines where the first three positions 059 are rolled up 060X All revenue code lines where the first three positions 060 are rolled up 062X All revenue code lines where the first three po
366. his report where the first three positions 060 are rolled up 329 SCIC 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 SCIC 0623 Displays by itself These fields are not populated on this report 329 SCIC All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 TOTAL 0023 Does not display These fields are not populated on this report 329 TOTAL 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 TOTAL 0274 Displays by itself These fields are not populated on this report 329 TOTAL 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 TOTAL 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 TOTAL 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 TOTAL 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 TOTAL 055X All revenue code lines These fields are not populated on this report where the first three positions 055 ar
367. ich the Paid Claims file data is processed The inpatient template report categories and the corresponding reports based on each report category are e 11x Inpatient Part A MSP LCC 11A Inpatient Long Term Care Part A PPS Interim Bills 11T Inpatient Long Term Care Part A PPS 11S Inpatient Rehabilitation PPS Interim Bills 11K Inpatient Part A Managed Care 118 Inpatient Rehabilitation Part A PPS 11R Inpatient PPS Interim Bills 119 Inpatient Part A 110 Inpatient Psych Part A PPS 11U Inpatient Psych PPS Interim Bills 11V e 115 Inpatient Fee Reimbursed 115 e 18x e Swing Bed SNF MSP LCC 18A e Swing Bed SNF 180 e 21x SNF Inpatient Part A MSP LCC 21A e SNF Inpatient Part A PPS 210 e 410 Religious Non Medical Inpatient Part A 410 All inpatient reports display consistent information at the top of the first page of each report The following provides an example of a report header for the inpatient reports Exhibit 4 1 Inpatient Report Header Program ID REDESIGN PROVIDER SUMMARY REPORT Page 1 Paid Dates 01 01 05 THRU 10 01 06 SNF INPATIENT PART A PPS Report amp OD44203 Report Run Date 02 05 07 Report Type 210 Provider FYE 06 30 Provider Number 195425 QUAKER HOME The following table contains a list of the fields displayed in the inpatient report header area and a description of these fields User Manual Inpatient
368. idation of Outpatient Claims Excluding MSP LCC Report 6 2 1000 Consolidated Summary of All Report Types Report 6 3 Report DetallS radere oid et ie eren e PAR NN Apang BUAN A 1 Report Data eir oe e Re a denen KIRARA B 1 Home Page Error Messages ssssssssssssssssss emen ns C 1 User Manual February 2009 Version No 2 0 Table of Contents x Exhibit C 2 Exhibit C 3 Exhibit C 4 Exhibit C 5 Exhibit C 6 Exhibit C 7 Exhibit C 8 Exhibit C 9 Exhibit C 10 Exhibit C 11 Exhibit C 12 Exhibit C 13 Exhibit C 14 Exhibit C 15 Exhibit C 16 Exhibit C 17 Exhibit D 1 Provider Statistical and Reimbursement System Summary Report Request Select Provider s Page Error Messages C 2 Summary Report Request Select Report s Page Error Messages C 3 Summary Report Request Select Service Period s Page Error and Warning Messages 2 n ene ene messen senes ense nee C 4 Summary Report Request Select Report Format Page Error Messages C 9 Summary Report Request Report Request Confirmation Page Error Messages ect xxr RR T exer Ua re dee na EE Ec ERR exe ERE a eK Ta C 9 Detail Report Request Select Provider s Page Error Messages C 11 Detail Report Request Select Report s Page Error Messages C 11 Detail Report Request Select Service Period s Page Error and Warning Messages 2 42s asaan an
369. ider Statistical and Reimbursement System Report Type Data Element Description 72A NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 72A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 810 MEDICARE DAYS Currently this field has no cost report usage 810 CLAIMS Currently this field has no cost report usage 810 TOTAL UNDUPLI CATED CENSUS The unduplicated census count of the hospice for all patients COUNT initially admitted and filing an election within the reporting period 810 UNDUP DAYS Currently this field has no cost report usage 810 HOURS REV CODE 0652 The number of hours applicable to this revenue code 810 UNITS REV CODE 0651 The number of units applicable to each revenue code 810 UNITS REV CODE 0652 The number of hours applicable to this revenue code 810 UNITS REV CODE 0655 The number of units applicable to each revenue code 810 UNITS REV CODE 0656 The number of units applicable to each revenue code 810 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue
370. ields are not populated on this report 399 SCIC 027X All revenue code lines Part B medical supplies charges with outlier where the first three positions 027 excluding 0274 are rolled up 399 SCIC 0274 Displays by itself Part B prosthetics and orthotics charges with outlier 399 SCIC 029X All revenue codes lines Part B durable medical equipment charges with outlier where the first three positions 029 are rolled up 399 SCIC 042X All revenue code lines Total Part A and Part B occupational therapy visit count during where the first three positions 042 SCIC only episode are rolled up 399 SCIC 043X All revenue code lines Total Part A and Part B occupational therapy visit count during where the first three positions 043 SCIC only episode are rolled up 399 SCIC 044X All revenue code lines Total Part A and Part B speech therapy visit count during SCIC where the first three positions 044 only episode are rolled up 399 SCIC 055X All revenue code lines Total Part A and Part B visit count related to nursing services where the first three positions 055 during SCIC only episode are rolled up 399 SCIC 056X All revenue code lines Total Part A and Part B visit count related to med soc serv where the first three positions 056 during SCIC only episode are rolled up User Manual February 2009 Version No 2 0 Report Data B 145 Provider Statistical and Reimbursement System
371. ific date Exhibit 2 14 Calendar A Dynamic Calendar Closed B Dynamic Calendar Opened lt lt September 2007 gt gt gt Mo Tu We Th Fr Sa Su 3 4 s 6 z 8 9 User Manual System Overview and Common Features February 2009 Version No 1 2 12 Provider Statistical and Reimbursement System Clicking the icon shown in Part A of the exhibit pops up the interactive calendar shown in Part B of the exhibit The user can use this calendar to scroll through different calendar years and months and locate a particular date Once the desired date month date and year is located the user selects that date by clicking on the date s day number this loads the desired date into the Calendar s associated date entry box 2 3 7 Command Buttons Command buttons allow a user to move backward or forward through the pages complete and submit a request reset default values apply values across report ranges or perform other functions as noted The following buttons are available to all users e Apply Clicking Apply applies entered date ranges to all providers and report periods e Back Clicking Back returns the user to the previous page e Continue Clicking Continue takes the user to the next page e Refresh Clicking Refresh reloads the current page e Reset Clicking Reset restores the values on the page to the default values e Submit Clicking Submit submits the request parameters and starts the report genera
372. iles from paid claims User Manual February 2009 Version No 2 0 Report Data B 61 Provider Statistical and Reimbursement System Report Type Data Element Description 22Z TOTAL GROSS FEE SCHEDULE AMT This is an accumulation of 10096 fee reimbursed ambulance services 22Z REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 22Z DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 22Z TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 22Z GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 22Z CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 22Z BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 22Z COINSURANCE The actual coinsurance amount from the paid claim record 22Z NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 22Z NET REI MBURSEMENT This amount represents an accumulation of interim payments made
373. ilitation facilities mainly services prior to January 1 1999 This report is used to determine if a provider has low utilization or no Medicare business for cost reporting The items reported on the Rehabilitation Facility 740 report are included on the Medicare Cost Report User Manual Outpatient Reports February 2009 Version No 2 0 5 38 Provider Statistical and Reimbursement System 5 8 10 Comprehensive Outpatient Rehabilitation Facilities 750 The Comprehensive Outpatient Rehabilitation Facilities 750 report shows cost reimbursement data if any by accommodation and ancillary service revenue codes This report captures lines of claims paid under the cost reimbursed method for Comprehensive Rehabilitation facilities mainly services prior to January 1 1999 This report is used to determine if a provider has low utilization or no Medicare business for cost reporting The items reported on the Comprehensive Outpatient Rehabilitation Facilities 750 report are included on the Medicare Cost Report 5 8 11 Community Mental Health Center 760 The Community Mental Health Center 760 report captures lines of claims paid under the cost reimbursed method for Community Health Centers for services prior to August 1 2000 The items reported on the Community Mental Health Center 760 report are included on the Medicare Cost Report 5 8 12 Critical Access Hospital 850 The Critical Access Hospital 850 report summarizes data for critica
374. im to be presented on the inpatient reports 4 1 1 11x Claims Processing If a claim s Bill Type is 11x the claim or claim lines are assigned to a report in the following sequence A claim is presented on the Inpatient Fee Reimbursed 115 report if any claim line HCPCS code is present and the corresponding Total Fee Schedule Amount is greater than zero 0 e A claim is presented on the Inpatient Part A MSP LCC 11A report if the claim level MSP LCC Indicator is M or the claim level indicator is FR Full Recovery e A claim is presented on the Inpatient Long Term Care Part A PPS Interim Bills 11T if the claim Service Thru Date is after September 30 2002 the provider is a long term care hospital Federal Specific Portion is not zero 0 and the Patient Status Code is 30 e A claim is presented on the Inpatient Long Term Care Part A PPS 11S report if claim Service Thru Date is after September 30 2002 the provider is a long term care hospital and Federal Specific Portion is not zero 0 e A claim is presented on the Inpatient Rehabilitation PPS Interim Bills 11K report if the Patient Status Code is 30 and any claim line Revenue Code is 0024 e A claim is presented on the Inpatient Part A Managed Care 118 report if any Condition Code is 04 Or 60 e A claim is presented on the Inpatient Rehabilitation Part A PPS 11R report if any claim line Revenue Code is 0024
375. imarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 712 CLAIMS Currently this field has no cost report usage 712 UNITS The number of units applicable to each revenue code 712 CHARGES The charges applicable to each revenue code 712 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 712 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 712 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 712 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 712 CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 712 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 712 COINSURANCE The actual coinsurance amount from the paid claim record 712 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 712 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments s
376. imbursement System ID Form Field User Type Validation Error Message E312 Select Paid From All Entry must be less than or Error E312 Paid Dates Date equal to corresponding do not have a valid date Service Period To Date range From from dates To to dates E312 Service Period From All Entry must be less than or Error E312 Period Date equal to corresponding service dates do not have Service Period To Date a valid date range for Provider ID 5 From from date To to dates E312 Service Period From All Entry must be less than or Error E312 Service Dates in Selected equal to its corresponding date s for Provider ID Service Periods Service Period To Date do not have a valid Table date range From from date To to date E312 Service Period To All Entry must be greater than Error E312 Service Dates or equal to corresponding dates for Provider ID Service Period From Date do not have a valid date range From from date To to date E312 Service Period To All Entry must be greater than Error E312 Service Dates in Selected or equal to corresponding dates for Provider ID Service Periods Service Period From Date do not have a valid date Table range From from date To to date E315 No Data Available All The number of reports Error E315 The request generated must be greater will not generate any than zero reports
377. in some instances but not all instances Exhibit A 1 Report Details Report Service Provider Provider Cost Report Type Report Name Category Type s Number Range Yes No 11A Inpatient Part A MSP LCC Inpatient Hospital Group 0001 0999 Yes 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 S001 S999 T000 T999 M300 M399 R300 R399 11K Inpatient Rehabilitation PPS Inpatient IRF Hospital 3025 3099 No Interim Bills T001 T999 R300 R399 11R Inpatient Rehabilitation Part Inpatient IRF Hospital 3025 3099 Yes A PPS T001 T999 R300 R399 11S Inpatient Long Term Care Inpatient LTCH Hospital 2000 2299 Yes Part A PPS 11T Inpatient Long Term Care Inpatient LTCH Hospital 2000 2299 No Part A PPS Interim Bills User Manual Report Details February 2009 Version No 2 0 A 1 Provider Statistical and Reimbursement System Report Type Report Name Service Category Provider Type s Provider Number Range Cost Report Yes No 11U Inpatient Psych Part A PPS Inpatient IPF Group 4000 4499 5001 5999 M300 M399 Yes 11V Inpatient Psych PPS Interim Bills Inpatient IPF Group 4000 4499 5001 5999 M300 M399 No 110 Inpatient Part A Inpatient Hospital Group 0001 0999 1200 1399 2000 2299 3025 3099 3300 3399 4000 4499 5001 5999 T000 T999 M300 M399 R300 R399 Yes 115 Inpatient Fee Reimbursed Inpatient Hospital Group 0001
378. informational only and should not be included in the cost report This amount occurs in cases where Medicare has made no payment on the claim yet classifies it as PR Partial Recovery because of the estimated pass through payments The actual pass through amounts will be determined in the cost report The MSP Pass Thru Reconciliation amount must be ignored for cost reporting 11V OTHER ADJ USTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 11V NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 11V CALCULATED NET REIMB FOR PIP CLAIMS For intermediary use Indicates that provider received PIP payments May be used to identify duplicate payments 11V ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 11A 18A 21A 118 and all other inpatient reports are transferred to the cost report 11V CLAIM INTEREST PAYMENTS Sum of interest paid on claims due to
379. investigate the amount by using Detail Other Reports 23P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 49 Provider Statistical and Reimbursement System Report Type Data Element Description 23P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 23P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 24P CLAIMS Currently this field has no cost report usage 24P UNITS The number of units applicable to each revenue code 24P CHARGES The charges applicable to each revenue code 24P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 24P DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 24P TOTAL COVERED CHARGES All Medicare covered char
380. ion No 2 0 4 5 Exhibit 4 4 Provider Statistical and Reimbursement System Inpatient 11x Provider Summary Report Template Page 1 Program ID REDESIGN Paid Dates 07 01 04 THRU 11 30 06 Report Run Date 03 22 06 Provider FYE 06 30 Provider Number 100001 SHANDS JACKSONVILLE MEDICAL CENTER STATISTIC SECTION DISCHARGES MEDICARE DAYS CLAIMS CHARGE SECTION ACCOMMODATION CHARGES REV CODE DESCRIPTION ono 0120 ROOM 8OARD PVT ROOM BOARD SEMI TOTAL ACCOMMODATIONS T1 ANCILLARY CHARGES REVCODE DESCRIPTION 0250 PHARMACY 0258 IV SOLUTIONS 0272 STERILE SUPPLY 0300 LABORATORY or LAB 0301 LAB CHEMISTRY 0305 LAB HEMATOLOGY 0324 DX X RAY CHEST 0390 BLOOD STOR PROC 0450 EMERG ROOM 0730 EKG ECG TOTAL ANCILLARY TOTAL COVERED CHARGES REIMBURSEMENT SECTION OPERATING HOSPITAL SPECIFIC Sep 22 2008 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PROVIDER SUMMARY REPORT Page 1 INPATIENT PART A MSP LCC Report OD44203 Report Type 11A SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 10 01 04 09 30 05 10 01 05 09 30 06 10 01 06 09 30 07 10 01 07 08 30 08 0 2 0 0 0 3 0 0 0 2 0 0 UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES L 0 00 1 696 00 L 000 L 000 o 0 00 2 1 365 00 0 0 00 o 50 00 0 0 00 3 2 064 00 0 000 0 000 UNTS CHARGES UNITS CHARGES UNTS CHARGES UNITS CHARGES L 0 00 80 1 424 70 0 0 00 o 000 0 0 00 2
381. ions 057 are rolled up 339 LUPA 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 LUPA 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 LUPA 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 LUPA 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 LUPA 0623 Displays by itself These fields are not populated on this report 339 LUPA All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 339 PEP 0023 Does not display These fields are not populated on this report 339 PEP 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 PEP 0274 Displays by itself These fields are not populated on this report 339 PEP 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 129 Provider Statistical and Reimbursement System Report Type Data Element Description
382. iption of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 340 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 340 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 340 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 340 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 340 COINSURANCE The actual coinsurance amount from the paid claim record 340 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 340 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 340 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 710 CLAI MS Currently this field has no cost report usage 710 UNITS Revenue Code 520 The number of units applicable to each revenue code 710 UNITS Revenue Code 521 The number of units applicable to each revenue code
383. irst three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 104 Provider Statistical and Reimbursement System Report Type Data Element Description 329 SCIC 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 SCIC 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 SCIC 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 SCIC 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 SCIC 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 SCIC 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 SCIC 0623 Displays by itself These fields are not populated on this report 329 SCIC All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 TOTAL 0023 Does not display These fields are not populated on this report 329 TOTAL 027X All revenue code lines
384. is displayed If the user is a CMS user Centers for Medicare and Medicaid Services is displayed Displays the identification number of the user currently logged on to the PS amp R System Displays the name of the page currently being accessed by the user Displays the current system date User Manual February 2009 Version No 1 System Overview and Common Features 2 3 2 2 1 1 CMS HHS gov Provider Statistical and Reimbursement System Clicking the CMS logo located in the upper left corner of the header opens a new browser window displaying the Centers Medicare and Medicaid Services website The following exhibit provides an example of the home page for the Centers for Medicare and Medicaid Services website Exhibit 2 3 Centers for Medicare and Medicaid Services Website gov MS Genters for Medicare amp Medicaid Services Improving the health safety and well being of America Search now Search Home Medicare Medicaid SCHIP About CMS Regulations amp Guidance Research Statistics Data amp Systems Outreach amp Education Tools People with Medicare amp Medicaid Questions CMS Programs amp Information Medicare Provider Enrollment amp Certification Fee for Service Payment Coverage CMS Forms Health Plans Coding Prescription Drug Coverage More Medicaid Medicaid Waiver amp Demonstration Projects Medicaid Consumer Enro
385. is determined by the type of data in the claim for example inpatient Part B Outpatient Skilled Nursing Facility etc 5 1 3 xxP Outpatient Prospective Payment System Claim lines that do not satisfy requirements for presentation on xxA reports are presented on the xxP Outpatient Prospective Payment System report template if the APC Code is greater than zero 0 and the Service From Date is on or after August 1 2000 5 1 4 xxZ Ambulance Blend Claim lines that do not satisfy requirements for presentation on xxP reports are presented on the xxZ Ambulance Blend report template if the Revenue Code is 54X the Service From date is on or after April 1 2002 and the HCPCS Code is and ambulance code The valid HCPCS codes for presentation on the xxZ Ambulance Blend report template are e A0425 A436 e A0030 e A0040 e A0050 e A0320 e A0322 e A0324 e A0326 e A0328 e A0330 e A0380 e A0390 e Q3019 Q3020 5 1 5 xx2 Vaccine Claim lines that do not satisfy requirements for presentation on xxZ reports are presented on the xx2 Vaccine report template if the Revenue Code is 636 or 771 the Total Fee Schedule Amount is zero 0 or blank the claim has a condition code of A6 and the line s corresponding cash deductible and coinsurance amounts are zero 0 The xx2 reports only contain those services that are not paid on a fee schedule and are not paid under the Outpatient Prospective Payment System 5 1 6 xx5 Fee
386. is field has no cost report usage 762 UNITS The number of units applicable to each revenue code 762 CHARGES The charges applicable to each revenue code 762 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 762 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 762 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 762 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 762 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 762 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 762 COINSURANCE The actual coinsurance amount from the paid claim record 762 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 762 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 762 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily f
387. is shown for informational purposes only User Manual February 2009 Version No 2 0 Report Data B 26 Provider Statistical and Reimbursement System Report Type Data Element Description 410 CAP FED SPECIFIC 10096 Note This field equals the federal specific field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period This field should be used by hold harmless providers only 410 CAP OUTLIER 10096 Note This field equals the outlier field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period 410 DRG CMG WEIGHT This field does not apply and will be zero 410 WEIGHT DISCHARGES This field does not apply and will be zero 410 DISCHARGE FRACTION This field does not apply and will be zero 410 DRG WEIGHT FRACTION This field does not apply and will be zero 410 DRG WEIGHT FRACTION This field does not apply and will be zero DISCHARGES 11U DISCHARGES This field is only valid for inpatient claims This indicates the number of patients discharged 11U MEDICARE DAYS The provider s hospital routine adults and peds days Note The provider s crosswalk may be used to allocate days for cost reporting purposes 11U CLAI MS Currently this field has no cost report usage 11U UNITS The number of units applicable to e
388. ities Vaccine Part B 100 Reasonable Cost 752 sssssseee Immer 5 29 5 6 11 Community Mental Health Center Vaccine Part B 10096 Reasonable COSE 762 Gana TA ds e cn ied a c dedo oe mc abi Moe eat co 5 29 5 6 12 ASC and ASC Fee Schedule Vaccine Part B 10096 Reasonable COSE 832 a o etr AA Qn devi Ex bac on 5 29 5 6 13 Critical Access Hospital Vaccines Part B 10096 Reasonable COSE 852m THEME 5 29 5 7 xx5 Fee Reimbursed Report Template ssssssssn nee 5 29 5 7 1 Inpatient Part B Fee Reimbursed 125 ssses 5 33 5 7 2 Outpatient Fee Reimbursed 135 0 2 mmn 5 33 5 7 3 Outpatient Other Fee Reimbursed 145 sesssseeeeee 5 33 5 7 4 SNF Inpatient Fee Reimbursed 225 sssssenn 5 33 5 7 5 SNF Outpatient Fee Reimbursed 235 sss 5 33 5 7 6 Home Health Part B Fee Reimbursed 345 sssessesseesesss 5 33 5 7 7 Federally Qualified Health Center Fee Reimbursed 735 5 33 5 7 8 Rehabilitation Facility Fee Reimbursed 745 ssssesseeseees 5 33 5 7 9 Comprehensive Outpatient Rehabilitation Facilities Fee Reimbursed 755 ain eoe ace RUE Ce E Ee ER ER NASAAN 5 33 5 7 10 Community Mental Health Center Fee Reimbursed 765 5 34 5 7 11 ASC and ASC Fee Schedule Fee Reimbursed 835 5 34 5 7 12 Critical Access Hospital Fee Reimbu
389. ity payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 11S MSP PASS THRU RECONCILIATION This field is informational only and should not be included in the cost report This amount occurs in cases where Medicare has made no payment on the claim yet classifies it as PR Partial Recovery because of the estimated pass through payments The actual pass through amounts will be determined in the cost report The MSP Pass Thru Reconciliation amount must be ignored for cost reporting 11S OTHER ADJ USTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 11S NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 11S CALCULATED NET REIMB FOR PIP CLAIMS For intermediary use Indicates that provider received PIP payments May be used to identify duplicate payments 11S ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field directly to the cost report worksheet E 1 in addition to the P
390. ive Outpatient Rehabilitation Facilities OPPS 75P The Comprehensive Outpatient Rehabilitation Facilities OPPS 75P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the Comprehensive Outpatient Rehabilitation Facilities OPPS 75P report are included on the Medicare Cost Report 5 4 12 Community Mental Health Center OPPS 76P The Community Mental Health Center OPPS 76P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the Community Mental Health Center OPPS 76P report are included on the Medicare Cost Report 5 4 13 Hospice Non Hospital Based OPPS 81P The Hospice Non Hospital Based OPPS 81P report captures data from all lines of a claim that were paid under Outpatient Prospective Payment System including lines paid as APC services packaged with them This report contains claim lines for services on or after August 1 2000 The items reported on the Hospice Non Hospital Based OPPS 81P report are included on the Medicare Cost Report 5 4 14 Hospice Hospital Based OPPS 82P The Hospice
391. ized Access to CMS Computer Services IACS IACS is CMS identification and authorization system for web based applications Providers will be instructed by their FI MAC when and how they should register If you would like more information regarding IACS prior to receiving instructions from the FI MAC you may view the IACS webpage http www cms hhs gov IACS 2 1 Access the PS amp R System Website Perform the following steps to access the PS amp R System l Login to the PS amp R system via the Individuals Authorized Access to CMS computer Services IACS system login screen as displayed below IACS is a CMS wide enterprise security and authentication system that is the gateway to many CMS systems including the PS amp R system cas Genters for Medicare amp Medicaid Services U S Department of Health amp Human Services O www hhs gov Individuals Authorized Access to the CMS Computer Services IACS Login to IACS The Federal Information Security Management Act FISMA of 2002 requires that the local system used to access CMS Computer Systems has up to date operating system patches and is running anti virus software You must have an IACS User ID and Password to login If this is your first time logging in please use the User ID and the one time password that was e mailed to you by IACS Effective September 29 2006 your password will be set to expire every sixty days In the event your password d
392. l Type the reason for the request to include with the report request Reason for Request can be up to 250 characters User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 21 Provider Statistical and Reimbursement System 9 Click Continue to continue to the next page to specify the request name and to view the selection criteria for the report s or click Back to return to the previous page The following page appears if you click Continue Cs Provider Statistical amp Reimbursement System Site Map Announcements FAQ Help Logout User ID TRTEST17 GLOBAL FI MAC 14000 Detail Report Request Thursday Aug Home Report Inbox Request Report Favorite Requests Request Summary Request Detail Detail Report Request 7 Confirm Report Request Report Request ID TRTEST17 D 9901 Your Request Name FfmrESTITO 3801 SS 50 Char Requested Provider s T01301 Requested Report s 110 115 118 114 120 122 125 124 12P 122 130 132 135 13A 13P 132 140 142 145 144 14P 180 184 831 832 835 834 83P BIZ 850 852 855 BSA 85Z No Data Available TO1301 115 118 11A 120 122 125 124 12P 12Z 130 132 135 13A 13P 13Z 140 142 14A 14P 180 184 831 832 835 83A 83P 83Z 852 854 852 Phi Excluded No Format CSV Paid Dates 01 01 2006 to 10 01 2006 Contact Info Primary First Name Jane Last Name Doe Phone 703 267 1212 E
393. l payment 11S INDIRECT MEDI CAL EDUCATION This is the indirect medical education adjustment payment to PPS teaching hospitals applicable to PPS capital payments 11S EXCEPTI ONS This is the per discharge exception interim payment for capital related costs that qualifying hospitals are entitled to receive in accordance with Medicare payment policy 11S TOTAL CAPITAL PAYMENTS This is the sum of the capital amounts for HSP FSP outlier hold harmless disproportionate share adjustment indirect medical education and exception payments 11S GROSS REIMBURSEMENT This amount is the sum of total operating and total capital payments 11S DEVICE CREDIT This amount represents the credit that a provider received to replace a medical device that may have been defective or under warranty This amount can be identified with a value code of FD on the claim 11S CASH DEDUCTIBLE The sum of actual cash deductible amount from the paid claim records 11S BLOOD DEDUCTIBLE The sum of actual blood deductible amount from the paid claim records User Manual February 2009 Version No 2 0 Report Data B 19 Provider Statistical and Reimbursement System Report Type Data Element Description 11S COINSURANCE The sum of actual coinsurance amount from the paid claim records 11S NET MSP PAYMENTS The sum of net payments made by a higher prior
394. l Based or Independent Renal Dialysis Center Fee Reimbursed 725 report If a claim line Revenue Code is 636 or 771 the corresponding Total Fee Schedule Amount is zero 0 or blank the claim has a condition code of A6 and the line s corresponding cash deductible and coinsurance amounts are zero 0 the claim line is presented on the Outpatient Part B Vaccine 132 report If a claim line s cash deductible coinsurance or net reimbursement amount is not equal to zero 0 the claim is presented on the Outpatient Cost Reimbursed 130 report If none of the previous conditions applies to the claim or claim lines the claim line is presented on the Hospital Based or Independent Renal Dialysis Center Fee Reimbursed 725 report Note that the xxM Medicare Secondary Payer Lower Cost or Charge MSP LCC and xx9 Episodes claims are presented on the common xxM xx9 report template User Manual Outpatient Reports February 2009 Version No 2 0 5 4 Provider Statistical and Reimbursement System 5 1 2 xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Claims that do not satisfy requirements for presentation on 72x reports are presented on the xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC report template if the MSP LCC Indicator is M or the Full Recovery Indicator is FR The specific xxA Medicare Secondary Payer Lower Cost or Charge report on which the claim is presented
395. l Based or Outpatient ESRD Hospital 0001 0999 No Independent Renal Dialysis 2300 2899 Center MSP LCC 2900 2999 3300 3399 3500 3799 720 Hospital Based or Outpatient ESRD Hospital 0001 0999 Yes Independent Renal Dialysis 2300 2899 Center Composite Rate 2900 2999 Services 3300 3399 3500 3799 725 Hospital Based or Outpatient ESRD Hospital 0001 0999 No Independent Renal Dialysis 2300 2899 Center Fee Reimbursed 2900 2999 3300 3399 3500 3799 73A Federally Qualified Health Outpatient FQHC 1000 1199 No Center MSP LCC 1800 1989 73P Federally Qualified Health Outpatient FQHC 1000 1199 Yes Center OPPS 1800 1989 730 Federally Qualified Health Outpatient FQHC 1000 1199 Yes Center 1800 1989 732 Federally Qualified Health Outpatient FQHC 1000 1199 Yes Center Vaccine Part B 1800 1989 10096 Reasonable Cost 735 Federally Qualified Health Outpatient FQHC 1000 1199 No Center Fee Reimbursed 1800 1989 74A Rehabilitation Facility Outpatient OPT 6500 6989 No MSP LCC 74P Rehabilitation Facility OPPS Outpatient OPT 6500 6989 Yes 740 Rehabilitation Facility Outpatient OPT 6500 6989 Yes 742 Rehabilitation Facility Outpatient OPT 6500 6989 Yes Vaccine Part B 10096 Reasonable Cost 745 Rehabilitation Facility Fee Outpatient OPT 6500 6989 No Reimbursed 75A Comprehensive Outpatient Outpatient CORF 3200 3299 No Rehabilitation Facilities 4500 4599 MSP LCC 4800 4899 75P Comprehensive Outpatient Outpatient CORF 3200 32
396. l access hospital services bill type 85x reimbursed on a cost basis The items reported on the Critical Access Hospital 850 report are included on the Medicare Cost Report 5 9 xxM xx9 Home Health Agency Report Template The xxM xx9 Medicare Secondary Payer Lower Cost or Charge MSP LCC and Episodes summary reports display summary services reimbursement and additional information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The services section is divided into Services without Outlier Services with Outlier and Total Services Payment types such as Full Episodes Lupa etc categorize the services section The reimbursement section shows how Gross Reimbursement and Net Reimbursement are calculated Finally the additional information section shows claim interest payments In addition the MSA supplemental report is generated for the Home Health PPS Part B Episodes 329 and Home Health PPS Part A Episodes 339 reports The user can choose to exclude this section The xxM xx9 Medicare Secondary Payer Lower Cost or Charge MSP LCC and Episodes detail reports display detail claim information reimbursements and additional information sections The claim information section contains data such as Part A Part B visits Fee Type HC
397. l revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 SCIC 0274 Displays by itself These fields are not populated on this report 339 SCIC 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 131 Provider Statistical and Reimbursement System Report Type Data Element Description 339 SCIC 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 SCIC 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 SCIC 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 SCIC 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 SCIC 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 SCIC 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 SCIC 058X All rev
398. l specific field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period This field should be used by hold harmless providers only Note This field is populated for IPPS Hospitals only 11K CAP OUTLIER 10096 This field equals the outlier field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period Note This field is populated for IPPS Hospitals only 11K DRG CMG WEIGHT This is the actual weight of the DRG CMG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS operating payments made to a specific provider 11K WEIGHT DISCHARGES This is the actual weight non transfer adjusted of the DRG determined by the PPS Pricer program divided by the discharges 11K DISCHARGE FRACTION For transfer cases the billed days are divided by the average length of stay for the DRG and the result is entered in this field The amounts in this field cannot exceed 1 0000 For non transfer cases the amount 1 0000 will always appear in this field 11K DRG WEIGHT FRACTION This is the actual weight of the DRG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS op
399. laim paid date range or click the calendar icon to select the start date using the calendar Scroll through the months and select the date to use The default value is the latest paid cycle date from the paid claim files loaded for the FI MAC Type the end date in MM DD YYYY format for the claim paid date range or click the calendar icon to select the end date using the calendar Scroll through the months and select the date to use Optional Select the Exclude check box to exclude any provider or reporting periods from the report s User Manual February 2009 Version No 2 0 Performing Tasks in the PS amp R 3 19 Provider Statistical and Reimbursement System 7 Click Continue to continue to the next page to specify the report format and contact information or click Back to return to the previous page The following page appears if you click Continue COS Provider Statistical amp Reimbursement System ap Announcements FAQ Help SHANDS JACKSONVILLE MEDICAL CENTER 100001 User ID PR Detail Report Req Wednesday October 15 Home Report Inbox Favorite Requests Request Summary Request Detail Detail Report Request 5 Select Report Format C PDF csv 6 Provide Contact Information Required fields Primary Secondary First Name First Name m Last Name Last Name C 3 o E mail KU E mail 3J Fax Fax o Reason for Request a Reason
400. laim record 71A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 71A COINSURANCE The actual coinsurance amount from the paid claim record 71A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 71A NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 71A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions User Manual February 2009 Version No 2 0 Report Data B 40 Provider Statistical and Reimbursement System Report Type Data Element Description 73A CLAIMS Currently this field has no cost report usage 73A UNITS The number of units applicable to each revenue code 73A CHARGES The charges applicable to each revenue code 73A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 73A DESCRIPTION The description of each revenue code and its associated covered units
401. lary 14A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 14A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 14A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record User Manual February 2009 Version No 2 0 Report Data B 37 Provider Statistical and Reimbursement System Report Type Data Element Description 14A COINSURANCE The actual coinsurance amount from the paid claim record 14A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 14A NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 14A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 22A CLAI MS Currently this field has no cost report usage 22A UNITS The number of units applicable to each revenue code 22A CHARGES The charges applicable to each revenue code 22A REV CODE Each revenue code and its associated covered units and charges See I
402. ld capital method 119 DSH This is the disproportionate share portion of the PPS capital payment 119 INDIRECT MEDI CAL EDUCATION This is the indirect medical education adjustment payment to PPS teaching hospitals applicable to PPS capital payments 119 EXCEPTI ONS This is the per discharge exception interim payment for capital related costs that qualifying hospitals are entitled to receive in accordance with Medicare payment policy 119 TOTAL CAPITAL PAYMENTS This is the sum of the capital amounts for HSP FSP outlier hold harmless disproportionate share adjustment indirect medical education and exception payments 119 GROSS REIMBURSEMENT This amount is the sum of total operating and total capital payments 119 DEVICE CREDIT This amount represents the credit that a provider received to replace a medical device that may have been defective or under warranty This amount can be identified with a value code of FD on the claim 119 CASH DEDUCTIBLE The sum of actual cash deductible amount from the paid claim records 119 BLOOD DEDUCTIBLE The sum of actual blood deductible amount from the paid claim records 119 COINSURANCE The sum of actual coinsurance amount from the paid claim records 119 NET MSP PAYMENTS The sum of net payments made by a higher priority payer under the MSP provisions is shown in this field Note Primary paymen
403. ld harmless providers only 11U CAP OUTLIER 10096 Note This field equals the outlier field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period 11U DRG CMG WEIGHT This field does not apply and will be zero 11U WEIGHT DISCHARGES This field does not apply and will be zero 11U DISCHARGE FRACTI ON This field does not apply and will be zero 11U DRG WEIGHT FRACTION This field does not apply and will be zero 11U DRG WEIGHT FRACTION This field does not apply and will be zero DISCHARGES 11V DISCHARGES This field is only valid for inpatient claims This indicates the number of patients discharged 11V MEDICARE DAYS The provider s hospital routine adults and peds days Note The provider s crosswalk may be used to allocate days for cost reporting purposes 11V CLAI MS Currently this field has no cost report usage 11V UNITS The number of units applicable to each revenue code Note for accommodations revenue codes this may include non covered days 11V CHARGES The charges applicable to each revenue code 11V REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 11V DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue co
404. le loaded for that FI MAC Provider User the latest paid date from a paid claim file loaded for the provider s FI MAC E007 Select Paid To Date All Entry must be less than or Error E007 Paid To equal to the default date date must be on or before CMS User the latest paid default dates date from any paid claim file FI MAC User the latest paid date from a paid claim file loaded for that FIMAC Provider User the latest paid date from a paid claim file loaded for the provider s FI MAC E008 Paid Date From Date All Entry must be greater than Error E008 Paid From or equal to 01 01 2006 date must be on or after 01 01 2006 E008 Select Paid From All Entry must be greater than Error E008 Paid From Date or equal to 01 01 2006 date must be on or after 01 01 2006 E008 Service Period From All Fields must not be null Error E008 Service start Dates in Selected date must be on or after Service Periods 2006 FYE Date plus 1 Table day E008 Service Period Start Parent Service start dates must Error E008 Service start Date Provider come after the provider s date must be on or after Freestanding 2006 FYE Date plus one day 2006 FYE Date plus 1 Child Provider day User Manual February 2009 Version No 2 0 Error Messages C 31 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message E010 Login
405. le medical equipment for LUPA where the first three positions 029 are rolled up 399 LUPA 042X All revenue code lines Total Part A and Part B physical therapy visit count during where the first three positions 042 LUPA episode are rolled up 399 LUPA 043X All revenue code lines Total Part A and Part B occupational therapy visit count during where the first three positions 043 LUPA episode are rolled up 399 LUPA 044X All revenue code lines Total Part A and Part B speech therapy visit count during LUPA where the first three positions 044 episode are rolled up 399 LUPA 055X All revenue code lines Total Part A and Part B visit count related to nursing services where the first three positions 055 during PEP episode are rolled up 399 LUPA 056X All revenue code lines Total Part A and Part B visit count related to med soc serv where the first three positions 056 are rolled up during LUPA episode User Manual February 2009 Version No 2 0 Report Data B 142 Provider Statistical and Reimbursement System Report Type Data Element Description 399 LUPA 057X All revenue code lines Total Part A and Part B visit count related to home health aide where the first three positions 057 serv during LUPA episode are rolled up 399 LUPA 058X All revenue code lines Part B Other Visits without outlier where the first three positions
406. lease choose a admission type must be selected before continuing System Error PS amp R Could not find the range ID Error E050 No range id found for E050 for the provider provider amp arg1 System Error PS amp R Exception occurred in the Error E051 Caught exception in E051 selectReportsByProviderType selectReportsByProviderType method amp arg1 System Error PS amp R Exception occurred in the Error E052 Caught exception in E052 selectProvidersByType selectProvidersByType amp arg1 method System Error PS amp R Exception occurred in the Error E054 Caught exception in E054 retrieveResults method retrieveResults amp arg1 System Error PS amp R Exception occurred in the Error E083 Caught exception in E083 selectProviders method selectProviders amp arg1 amp arg2 System Error PS amp R Exception occurred in the Error E084 Caught exception in E084 setUpChildProvider method setUpChildProvider amp arg1 amp arg2 System Error PS amp R No Providers were selected Error E086 No Providers E086 available in buildSelected System Error PS amp R Please enter both From and Error E087 Both From and To E087 To Date for a particular period Date has to be present for period amp arg1 User Manual February 2009 Version No 2 0 Error Messages C 23 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message I
407. lected Select the By Report Group option and then select the report group to generate Once a report group is highlighted click the 55 button to select the report group Once a report group is selected highlight the report group from the list of selected report groups and click the button to remove the report group To locate a report group in the list of report groups type the desired report group in the Search text box to scroll to the report group based on the entered criteria Include 998 Report Optional Select the check box to include the Consolidation of Outpatient Claims Excluding MSP LCC 998 report in this request Exclude PHI on Reports Optional Select the check box to exclude all personal health information on the reports generated in this request By Report Type Required if neither By Service Type nor By Report Group is selected Select the By Report Type option and then select the report type to include in the report Once a report type is highlighted click the 55 button to select the report type Once a report type is selected highlight the report type from the list of selected report types and click the button to remove the report type To locate a report type in the list of report types type the desired report type in the Search text box to scroll to the report type based on the entered criteria Exclude PHI on Reports Optional Select the check box to exclude all personal health information on the reports gen
408. led up 329 SCIC 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 SCIC 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 SCIC 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 SCIC 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 SCIC 0623 Displays by itself These fields are not populated on this report 329 SCIC All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 TOTAL 0023 Does not display These fields are not populated on this report 329 TOTAL 027X All revenue code lines Part B durable medical equipment payments without outlier where the first three positions 027 excluding 0274 are rolled up 329 TOTAL 0274 Displays by itself Total Part B Prosthetics amp Orthotics charges without outlier 329 TOTAL 029X All revenue codes lines Total Part B Durable Med Equip charges without outlier where the first three positions 029 are rolled up 329 TOTAL 042X All revenue code lines Part B physical therapy count for full episodes without outlier where the first three positions 042 are rolled up 3
409. led up 329 SCIC PEP 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 SCIC PEP 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 SCIC PEP 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 SCIC PEP 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 103 Provider Statistical and Reimbursement System Report Type Data Element Description 329 SCIC PEP 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 SCIC PEP 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 SCIC PEP 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 SCIC PEP 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 SCIC PEP 060X All revenue code lines Th
410. lines These fields are not populated on this report where the first three positions 055 are rolled up 339 LUPA 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 LUPA 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 LUPA 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 LUPA 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 LUPA 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 LUPA 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 LUPA 0623 Displays by itself These fields are not populated on this report 339 LUPA All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 339 PEP 0023 Does not display These fields are not populated on this report 339 PEP 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 PEP 0274 Displays by itself These fields
411. lled up 329 LUPA 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 LUPA 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 101 Provider Statistical and Reimbursement System Report Type Data Element Description 329 LUPA 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 LUPA 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 LUPA 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 LUPA 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 LUPA 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 LUPA 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 LUPA 0623 Displays by itself These fields are not populated on this report 329
412. llment amp Coverage Medicaid Prescription Drugs More SCHIP Low Cost Health Insurance National SCHIP Policy More About CMS Agency Information Career Information More Featured Content fx Receive Email Updates on CMS topics of interest to you All Fee For Service Providers Browse by Special Topic American Indian Alaska Native Center End Stage Renal Disease ESRD Center Legislative Affairs Center Medicare Coverage Center Newsroom Center Regulations amp Guidance Manuals Transmittals Quarterly Provider Updates Legislation Health Insurance Portability and Accountability Act HIPAA More Research Statistics Data amp Systems CMS Information Technology Statistics Trends amp Reports Computer Data amp Systems More Outreach amp Education Medicare Learning Network Partner with CMS Training More Resources amp Tools Frequently Asked Questions CMS Events amp Conferences Mailing Lists More Ombudsman Center Open Enrollment Center Partnering with CMS Center People With Medicare amp Medicaid Center Quality of Care Center Web Policies amp Important Links Privacy Polic Department of Health amp Human Services Medicare gov USA gov Help k Email h Print CMS Highlights Nursing Home Compare Five Star Rating System 2009 Medi
413. luded on the Medicare Cost Report User Manual February 2009 Version No 2 0 Outpatient Reports 5 46 Provider Statistical and Reimbursement System 5 11 81x 82x Hospice Report Template The 81x 82x Hospice Provider Summary report template displays summary statistic charge reimbursement and additional information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The data displayed in each section is determined by the report selected for generation The statistic section shows the Medicare days Claims and Total unduplicated census count for each reporting period The charge section displays the number of units Unduplicated days and the total dollar amount of the revenue code being reported The reimbursement section displays how Net Reimbursement is calculated Finally the additional information section displays the claim interest payments The 81x 82x Hospice Payment Reconciliation detail report template is divided into Claim Information Reimbursements and Additional Information sections The claim information section contains patient information such as the patient name DCN description Unduplicated days Line Item Reimbursement and the charges for the revenue codes The reimbursements section shows how Net Reimbursement is calculat
414. m of the operating amounts for HSP FSP outlier DSH LI P IME teaching adjustment new technology IPF ECT and exception payments User Manual February 2009 Version No 2 0 Report Data B 15 Provider Statistical and Reimbursement System Report Type Data Element Description 11R HOSPITAL SPECIFIC This is the hospital specific portion of the PPS payment for capital The field will be zero for providers paid based on the hold harmless old capital or the hold harmless 100 percent federal method and for new hospitals during their first two years of operation 11R FEDERAL SPECIFIC This field includes the federal portion of the PPS payment for capital This field will also include the new capital amount for hospitals paid under the hold harmless old capital method 11R OUTLIER This field will show the outlier portion of the PPS payment for capital 11R HOLD HARMLESS This field shows the hold harmless amount paid for old capital based on the hold harmless old capital method 11R DSH This is the disproportionate share portion of the PPS capital payment 11R INDIRECT MEDI CAL EDUCATION This is the indirect medical education adjustment payment to PPS teaching hospitals applicable to PPS capital payments 11R EXCEPTIONS This is the per discharge exception interim payment for capital related costs that qualifying hospitals are entitled to recei
415. made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 53 Provider Statistical and Reimbursement System Report Type Data Element Description 73P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 73P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 74P CLAIMS Currently this field has no cost report usage 74P UNITS The number of units applicable to each revenue code 74P CHARGES The charges applicable to each revenue code 74P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 74P DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 74P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 74P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim
416. mation section contains patient information such as the patient name DCN HCPCS and the charges for the revenue codes The reimbursements section shows how net reimbursement is calculated The additional information section shows the deductible amounts coinsurance and the claim interest The report template also provides a monthly totals section that sums the information from the sections above An example of the 72x Provider Summary report template and the 72x Hospital Based or Independent Renal Dialysis Center Payment Reconciliation detail report template follow User Manual Outpatient Reports February 2009 Version No 2 0 5 7 Provider Statistical and Reimbursement System Exhibit 5 1 Outpatient 72x Provider Summary Report Template Program ID REDESIGN Paid Dates 01 01 04 THRU 10 01 06 Report Run Date 02 02 07 Provider FYE 12 31 PROVIDER STATISTICAL Provider Number TO2581 INDIAN BEACH DIALYSIS CENTER STATISTIC SECTION CLAIMS CHARGE SECTION REV CODE ESRD COND CODE DESCRIPTION 0821 71 HEMO COMPOSITE 76 HEMO COMPOSITE on 73 CAPD COMPOSITE 74 CAPD COMPOSITE 0851 73 CCPD COMPOSITE 74 CCPD COMPOSITE TOTAL COVERED CHARGES REIMBURSEMENT SECTION GROSS REIMBURSEMENT LESS CASH DEDUCTIBLE COINSURANCE NET MSP PAYMENTS ESRD REDUCTION NETWORK PAYMENTS NET REIMBURSEMENT ADDITIONAL INFORMATION SECTION CLAIM INTEREST PAYMENTS CONDITION CODE KEY AND REIMBURSEMENT SYSTEM PROVIDER SUMMARY REPORT Page 1 HOS
417. mbers User Manual February 2009 Version No 2 0 Error Messages C 15 C 10 Provider Statistical and Reimbursement System Detail Report Request Select Report Format The Detail Report Request Select Report Format page error messages are presented in the following table Exhibit C 10 Detail Report Request Select Report Format Page Error Messages Form Field CSV Radio Button User Type CMS FI MAC Validation If the PDF radio button is not selected this must be selected Error Message Error E046 No report format was selected Please choose a report format before continuing ID E046 PDF Radio Button CMS FI MAC If the CSV radio button is not selected this must be selected Error E046 No report format was selected Please choose a report format before continuing E046 Selection of the PDF Format and then clicking Continue All If the PDF selected request results in a PDF file which is over the allowable PDF file size and then clicks Continue Error E330 This request exceeds the maximum allowable PDF file size for Provider s providers which exceed pdf file size limitations inserted here separated by commas Please select CSV or change request parameters E330 Primary First Name field Provider Field must not be null Error E112 No primary First Name entered Please enter a primary First Nam
418. mbursement System Exhibit 5 7 Outpatient xxP Outpatient Prospective Payment System OPPS Provider Summary Report Template Last Page Program ID REDESIGN Paid Dates 02 4 THRU 10 01 06 Report Run Date 02 01 07 Provider FYE 12 21 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PROVIDER SUMMARY REPORT Page 2 OUTPATIENT OPPS Report 0044203 Report Type 13F Provider Number T00007 PETERBORO GENERAL HOSPITAL GROSS APC PAYMENT PLUS OUTLIER GROSS REIMBURSEMENT LESS CASH DEDUCTIBLE BLOOD DEDUCTIBLE COINSURANCE NET MSP PAYMENTS MSP RECONCILIATION OTHER ADJUSTMENTS PSYCH REDUCTION NET REIMBURSEMENT ADDITIONAL INFORMATION SECTION CLAIM INTEREST PAYMENTS ELECTED COINSURANCE Feb 1 2007 SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 04 12 31 04 No Data Requested No Data Requested No Data Requested 8 144 57 20 52 8 165 09 100 00 0 00 1 829 57 0 00 0 00 0 00 50 00 56 235 52 0 00 0 00 23 7 57 38 PM User Manual February 2009 Version No 2 0 Outpatient Reports 5 17 Exhibit 5 8 Provider Statistical and Reimbursement System Outpatient xxP Outpatient Prospective Payment System OPPS Payment Reconciliation Detail Report Template First Page Program ID REDESIGN Service Month End 04 30 04 Report Run Date 02 07 07 Provider FYE 12 21 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Provider Numb
419. mely claims processing Currently this field has no cost report usage 11T IRF PENALTY AMOUNT The 2596 penalty assessed for failure to submit IRF PAI data timely 11T LTCH SHORT STAY OUTLIER PAYMENTS The per diem payments made under PPS to the provider for a patient s stay in the facility prior to being transferred to another facility These payments are included in the net reimbursement field This field is shown for informational purposes only User Manual February 2009 Version No 2 0 Report Data B 23 Provider Statistical and Reimbursement System Report Type Data Element Description 11T CAP FED SPECIFIC 10096 Note This field equals the federal specific field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period This field should be used by hold harmless providers only 11T CAP OUTLIER 10096 Note This field equals the outlier field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period 11T DRG CMG WEIGHT This is the actual weight of the DRG CMG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS operating payments made to a specific provider 11T WEIGHT DISCHARGES This is the
420. ment System C Error Messages This appendix documents the error messages used throughout the PS amp R System This appendix is organized according to the following sections e Home Page e Summary Report Request Select Provider s e Summary Report Request Select Report s e Summary Report Request Select Service Period s e Summary Report Request Select Report Format e Summary Report Request Report Request Confirmation e Detail Report Request Select Provider s e Detail Report Request Select Report s e Detail Report Request Select Service Period s e Detail Report Request Select Report Format e Detail Report Request Report Request Confirmation e Detail Report Request Load Control e Detail Report Request FI MAC Provider Requests e Miscellaneous Report Request Select Reports e Detail Report Request Miscellaneous e Miscellaneous System Error Messages e Error Codes in Numeric Order Each section provides the form on which the error or warning message results the type of user validation the error message and where relevant the error ID Cal Home Page The Home page error messages are presented in the following table Exhibit C 1 Home Page Error Messages Form Field User Type Validation Error Message No Claims loaded PS amp R There must be claims loaded Error E318 No claims have for a given provider No been loaded for provider ID reports will be generated with 5 0 claims loaded I
421. ments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 74P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 75P CLAIMS Currently this field has no cost report usage 75P UNITS The number of units applicable to each revenue code 75P CHARGES The charges applicable to each revenue code 75P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 75P DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 75P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 75P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 75P OUTLIER The outlier portion of the OPPS payment for the APC 75P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 75P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 75P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 75P COINSURANCE The actual coinsurance
422. mmary Report Template First Page 5 40 Outpatient xxM xx9 Medicare Secondary Payer Lower Cost or Charge MSP LCC and Episodes Summary Report Template Second Page 5 41 Outpatient xxM xx9 Medicare Secondary Payer Lower Cost or Charge MSP LCC and Episodes Summary Report Template Last Page 5 42 Outpatient xxM xx9 Medicare Secondary Payer Lower Cost or Charge MSP LCC and Episodes Payment Reconciliation Detail Report Template 3 tienen rer i ae BNG Neri UBO EBA bee Dit 5 43 Outpatient 322 332 Home Health Agency Summary Report Template 5 45 Outpatient 322 332 Home Health Agency Payment Reconciliation Detail Report Template 20 2000 2 5 46 Outpatient 81x 82x Hospice Summary Report Template 5 48 Outpatient 81x 82x Hospice Payment Reconciliation Detail Report Template NANANA NG a teg tine Maa baia 5 49 Outpatient 831 ASC and ASC Fee Schedule After 12 90 Provider Summary Report First Page sssssssssssssmm mme 5 51 Outpatient 831 ASC and ASC Fee Schedule After 12 90 Provider Summary Report Last Page sssssssssssssm memes eren 5 52 Outpatient 831 ASC and ASC Fee Schedule After 12 90 Payment Reconciliation Detail Report First Page ccccceseeeeeeeeeeeeeeeeeeeeeenees 5 53 Outpatient 831 ASC and ASC Fee Schedule After 12 90 Payment Reconciliation Detail Report Last Page 1 m 5 54 998 Consol
423. mt 36496 Recpt Dt 03 29 04 0258 Coins 12455 Caim Report Spits La Paid Ot 05 00 04 0272 2 MSP 020 Service From 06 19 00 0320 76000 1 Net Reimb 17134 Service Thru 06 19 00 0370 1 0490 62289 1 TOTAL 7 122808 41755 000 000 245 61 0 00 171 94 364 96 Monthly Totals for PARROTHEAD MEDICAL CENTER for service month end 11 30 99 Reimbursements Additional Information Sindrd Gross Reimb 417 55 MSP Cash Deduct 0 00 Gross Cash Blood Une item Units Changes Com MSP Ownd MSP Blood Deduct 0 00 Relmb Deduct Deduct Reimb Amt LESS MSP Cola 000 TOTAL 7 122805 41755 000 000 24561 000 171 94 36496 Cash Deduct 000 Claim Interest 0 00 Blood Deduct 000 Stndird Ovrhd Amt 36496 Coins 245 61 usr poo Net Reimbs 17194 Feb 19 2007 1 10 37 23 AM User Manual February 2009 Version No 2 0 Outpatient Reports 5 53 Provider Statistical and Reimbursement System Exhibit 5 31 Outpatient 831 ASC and ASC Fee Schedule After 12 90 Payment Reconciliation Detail Report Last Page PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page 2 Service Month End 06 30 00 ASC AND ASC FEE SCHEDULE AFTER 12 90 Report amp 0044202 Report Run Date 02 19 07 Report Type 831 Provider FYE 09 30 Paid Dates 01 01 80 to 10 01 06 Provider Number 100028 PARROTHEAD MEDICAL CENTER nM Patnt Nm COOPB Bil freq
424. n 11K FEDERAL SPECIFIC This field includes the federal portion of the PPS payment for capital This field will also include the new capital amount for hospitals paid under the hold harmless old capital method 11K OUTLIER This field will show the outlier portion of the PPS payment for capital 11K HOLD HARMLESS This field shows the hold harmless amount paid for old capital based on the hold harmless old capital method 11K DSH This is the disproportionate share portion of the PPS capital payment 11K INDIRECT MEDICAL EDUCATION This is the indirect medical education adjustment payment to PPS teaching hospitals applicable to PPS capital payments 11K EXCEPTI ONS This is the per discharge exception interim payment for capital related costs that qualifying hospitals are entitled to receive in accordance with Medicare payment policy 11K TOTAL CAPITAL PAYMENTS This is the sum of the capital amounts for HSP FSP outlier hold harmless disproportionate share adjustment indirect medical education and exception payments 11K GROSS REIMBURSEMENT This amount is the sum of total operating and total capital payments User Manual February 2009 Version No 2 0 Report Data B 12 Provider Statistical and Reimbursement System Report Type Data Element Description 11K DEVICE CREDIT This amount represents the credit that a provid
425. n if the report contains fewer than four reporting periods The data displayed in each section is determined by the report selected for generation The statistic section shows the number of claims for each reporting period The charge section displays the number of units and the total dollar amount of the revenue code being reported The reimbursement section displays how Net Reimbursement is calculated Finally the additional information section displays the claim interest payments and the elected coinsurance The xxP Outpatient Prospective Payment System OPPS Payment Reconciliation detail report template is divided into Claim Information Reimbursements and Additional Information sections The claim information section contains patient information such as the patient name DCN HCPCS total and the charges for the revenue codes The reimbursements section shows how Net Reimbursement is calculated The additional information section shows the deductible amounts claim interest and coinsurance The report template also provides a monthly totals section that sums the information from the sections above An example of the xxP Outpatient Prospective Payment System OPPS Provider Summary report template and the xxP Outpatient Prospective Payment System OPPS Payment Reconciliation Detail Report template follow User Manual Outpatient Reports February 2009 Version No 2 0 5 15 Provider Statistical and Reimbursement System Exhibit 5 6 Out
426. n is displayed at the end of the report The DRG section shows information that is grouped by DRG codes The DRG Section displays data for four service periods and contains information such as Discharges Medicare Days Gross Reimbursement and MSP Payment The fields in this section are totaled at the bottom of the column The Inpatient 11x Payment Reconciliation Detail reports display claim reimbursement and additional information charges for each individual claim submitted by the provider for the specified reporting period Each reporting period for at lease one reporting period up to a maximum of four reporting periods are presented in chronological order with the earliest reporting period displayed first All subsequent reporting periods are displayed following the previous reporting period at the end of each reporting period Each claim displays patient identification information the period of service associated with the claim and a list of revenue codes number of units and total amount of charges associated with each revenue code included in the claim In the Additional Information Section in detail reports the MSP Cash Deductible MSP Blood Deductible MSP Coinsurance Claim Report Splits and Capital Pay Code fields display An example of the Inpatient 11x Provider Summary report template and the Inpatient 11x Payment Reconciliation Detail report template follow User Manual Inpatient Reports February 2009 Vers
427. na nna NAN m I see ehem rennen e eterna C 12 Detail Report Request Select Report Format Page Error Messages C 16 Detail Report Request Report Request Confirmation Page Error MessagesC 17 Detail Report Request FI MAC Provider Requests Page Error Messages C 18 Miscellaneous Report Request Select Reports Page Error Messages C 20 Detail Report Request Load Control Page Error Messages C 21 Detail Report Request Miscellaneous Page Error Messages C 22 Miscellaneous System Error Messages ssssssssssn me C 22 Error Messages in Numeric Order ssssssssss mm C 29 Glossaty zr ERR USE E IEEE REDDE MEUS D 1 User Manual February 2009 Version No 2 0 Table of Contents xi Provider Statistical and Reimbursement System 1 Introduction The Provider Statistical and Reimbursement PS amp R System produces a variety of reports for Fiscal Intermediaries FIs Medicare Administrative Contractors MACs the Centers for Medicare and Medicaid Services CMS and Medicare Part A providers These reports accumulate statistical and payment data for hospitals hospital complexes skilled nursing facilities hospices end stage renal disease facilities comprehensive outpatient rehabilitation facilities and home health agencies The PS amp R system is comprised of many web pages that allow Fiscal Intermediary Medicare Administrative Contractor users CMS users and
428. nce of report type assignment for outpatient claims in addition to a description of each of the outpatient reports Chapter 4 Inpatient Reports provides a description of the inpatient reports available in the PS amp R System See Appendix B Report Data for a definition of the data elements available on reports 5 1 Outpatient Report Type Assignment Outpatient claims and claim lines including 34x home health agency and hospice claims submitted to the PS amp R System in the Paid Claims file are assigned to a report type in the following sequence e 72x Hospital Based or Independent Renal Dialysis Center e xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC e xxP Outpatient Prospective Payment System e xxZ Ambulance Blend e xx2 Vaccine User Manual Outpatient Reports February 2009 Version No 2 0 5 3 Provider Statistical and Reimbursement System e xx5 Fee Reimbursed e 831 ASC and ASC Fee Schedule After 12 90 e xx0 All Other For 32x and 33x home health agency HHA claims submitted to the PS amp R System the claims are assigned to a report type in the following sequence e xxM Medicare Secondary Payer Lower Cost or Charge MSP LCO e xx2 RAP e xx9 Episodes Hospice claims submitted to the PS amp R System are assigned to a report type in the following sequence e xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC e xxP Outpatient Prospective Payment System e xx0 All Other Th
429. nclude payments such as bi weekly pass through payments lump sums and financial adjustments etc 132 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 142 CLAIMS Currently this field has no cost report usage 142 UNITS The number of units applicable to each revenue code 142 CHARGES The charges applicable to each revenue code 142 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 142 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 142 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 142 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 142 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 142 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record User Manual February 2009 Version No 2 0 Report Data B 66 Provider Statistical and Reimbursement System Report Type Data Element Description 142 COINSURAN
430. nd displays Provider Statistical amp Reimbursement System the user s organization the user s ID the current date the name of the page currently loaded in the Content section and links to other support pages in the system e Menu Bar The menu bar is displayed horizontally across the top of all pages just below the page header The menu bar provides hyperlinks to the system functions applicable to the user s type e Content The Content area is the section with which the user interacts to perform system functions the Content s appearance varies by page The header and menu bar are discussed in this chapter The individual options available from the menu bar and the contents areas are discussed in Chapter 3 Performing Tasks in the PS amp R The web pages throughout the system use common controls familiar to most internet users For example the Tab key can be used to move the cursor from field to field moving across the page from left to right and from top to bottom If a button is highlighted you can press Enter to activate the button In drop down lists press the up and down arrows to move the previous or next value For check boxes and radio buttons press the space bar to toggle the selection of the value 2 2 1 Header Area The Header portion of the PS amp R System contains basic information that is displayed on each page within the system An example of the header information that appears on all pages is provided as follows
431. net MSP payment and net reimbursement amounts for each of the reporting periods presented on the report The Additional Information Section displays calculated net reimbursement for PIP actual claim payments for PIP and claim interest payments for each of the reporting periods presented on the report Additionally individual resource utilization group RUG utilization is displayed by revenue code to assist in the completion of Worksheets 5 7 of the Medicare Cost Report The Inpatient 18x and 21x Payment Reconciliation Detail reports display detailed claim information reimbursements and additional MSP deductible and coinsurance information for each claim included in the reporting period Additionally service period and report type totals are provided for each of the service periods included in the report An example of the Inpatient 18x and 21x Provider Summary report template and the Inpatient 18x and 21x Payment Reconciliation Detail report template follow User Manual Inpatient Reports February 2009 Version No 2 0 4 15 Provider Statistical and Reimbursement System Exhibit 4 12 Inpatient 18x and 21x Provider Summary Report Template Page 1 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page 1 Paid Dates 01 01 04 THRU 10 01 05 SWING BED SNF Report OD24202 Report Run Date 02 05 07 Report Type 180 Provider FYE 12 31 Provider Number T02300 SNOW BIRD HOSPITAL SER
432. ng period 82A UNDUP DAYS Currently this field has no cost report usage 82A HOURS The number of hours applicable to this revenue code 82A UNITS REV CODE 0651 The number of units applicable to each revenue code 82A UNITS REV CODE 0652 The number of hours applicable to this revenue code 82A UNITS REV CODE 0655 The number of units applicable to each revenue code 82A UNITS REV CODE 0656 The number of units applicable to each revenue code 82A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 82A DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 82A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 82A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 82A DEDUCTIBLES The actual deductible amount from the paid claim record 82A COINSURANCE The actual coinsurance amount from the paid claim record 82A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 82A MSP RECONCILIATION This field is the accumulation of the difference between the M
433. nits applicable to each revenue code 132 CHARGES The charges applicable to each revenue code User Manual February 2009 Version No 2 0 Report Data B 65 Provider Statistical and Reimbursement System Report Type Data Element Description 132 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 132 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 132 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 132 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 132 CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 132 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 132 COINSURANCE The actual coinsurance amount from the paid claim record 132 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 132 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not i
434. not please investigate the amount by using Detail Other Reports 410 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 410 CALCULATED NET REIMB FOR PIP CLAIMS For intermediary use Indicates that provider received PIP payments May be used to identify duplicate payments 410 ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 11A 18A 21A 118 and all other inpatient reports are transferred to the cost report 410 CLAIM INTEREST PAYMENTS Sum of interest paid on claims due to untimely claims processing Currently this field has no cost report usage 410 IRF PENALTY AMOUNT The 2596 penalty assessed for failure to submit IRF PAI data timely 410 LTCH SHORT STAY OUTLIER PAYMENTS The per diem payments made under PPS to the provider for a patient s stay in the facility prior to being transferred to another facility These payments are included in the net reimbursement field This field
435. ns 043 are rolled up 044X All revenue code lines where the first three positions 044 are rolled up 055X All revenue code lines where the first three positions 055 are rolled up 056X All revenue code lines where the first three positions 056 are rolled up 057X All revenue code lines where the first three positions 057 are rolled up 058X All revenue code lines where the first three positions 058 are rolled up 059X All revenue code lines where the first three positions 059 are rolled up 060X All revenue code lines where the first three positions 060 are rolled up 062X All revenue code lines where the first three positions 062 excluding 0623 are rolled up 0623 Displays by itself All other Rev Codes display as they come in on the claim they do not roll up 33M FULL EPISODES This is the Part B MSP LCC information 33M LUPA EPISODES This is the Part B MSP LCC information 33M PEP ONLY EPISODES This is the Part B MSP LCC information 33M SCIC ONLY EPISODES This is the Part B MSP LCC information 33M SCIC WITHIN A PEP This is the Part B MSP LCC information 33M TOTAL This is the Part B MSP LCC information User Manual February 2009 Version No 2 0 Report Data B 138 Provider Statistical and Reimbursement System Report Type Data Element Description 33M VI
436. nt Description 339 TOTAL 042X All revenue code lines Total Part B physical therapy count without outlier where the first three positions 042 are rolled up 339 TOTAL 043X All revenue code lines Total Part B occupational therapy count without outlier where the first three positions 043 are rolled up 339 TOTAL 044X All revenue code lines Total Part B speech count without outlier where the first three positions 044 are rolled up 339 TOTAL 055X All revenue code lines Total Part B nursing count without outlier where the first three positions 055 are rolled up 339 TOTAL 056X All revenue code lines Total Part B Med Soc Serv without outlier where the first three positions 056 are rolled up 339 TOTAL 057X All revenue code lines Total Part B home health aide count without outlier where the first three positions 057 are rolled up 339 TOTAL 058X All revenue code lines Total Part B Other Visits without outlier where the first three positions 058 are rolled up 339 TOTAL 059X All revenue code lines These fields are not normally used where the first three positions 059 are rolled up 339 TOTAL 060X All revenue code lines Total Part B Oxygen charges without outlier where the first three positions 060 are rolled up 339 TOTAL 062X All revenue code lines Total Part B Med Supplies charges without outlier where the first three positions 062 are rolled up 339 TOTAL 0623 Displays by itsel
437. nt System OPPS Report Template 5 15 5 4 1 Inpatient Part B OPPS 12P 20 22 emen me mene 5 20 5 4 2 Outpatient OPPS 13P 2 2 mmm eese rennes 5 20 5 4 3 Outpatient Other OPPS 14P ssssssssssssse mme mem 5 20 5 4 4 SNF Outpatient OPPS 22P cccccce cscs eceeee eee eeaeeaeeeaneeseeeneeenes 5 20 5 4 5 SNF Outpatient OPPS 23P 20 220 cece eme memes 5 20 5 4 6 SNF Outpatient OPPS 24P ccccccee ese e cece ee eeeeeeeeeaeeeaeeeneteneeenes 5 20 5 4 7 Home Health Outpatient OPPS not HHPPS 34P sssssse 5 20 5 4 8 Clinic Rural Health OPPS 71P 22 a 5 21 5 4 9 Federally Qualified Health Center OPPS 73P 2 2 5 21 5 4 10 Rehabilitation Facility OPPS 74P sasaasaanaaaa eee eee HH 5 21 5 4 11 Comprehensive Outpatient Rehabilitation Facilities OPPS 75P 5 21 5 4 12 Community Mental Health Center OPPS 76P 200 0 5 21 5 4 13 Hospice Non Hospital Based OPPS 81P 00 2 0 Ka 5 21 5 4 14 Hospice Hospital Based OPPS 82P 20002 a 5 21 5 4 15 ASC and ASC Fee Schedule OPPS 83P eseese reenen 5 21 5 5 xxZ Ambulance Blend Report Template maaasaasanaaaaasananaasanannananaanana 5 22 5 5 1 Inpatient Ambulance Blend Effective 04 01 02 12Z 5 24 5 5 2 Outpatient Amb
438. nual February 2009 Version No 2 0 Report Data B 94 Provider Statistical and Reimbursement System Report Type Data Element Description 329 FULL 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 FULL 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 FULL 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 FULL 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 FULL 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 FULL 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 FULL 0623 Displays by itself These fields are not populated on this report 329 FULL AII other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 LUPA 0023 Does not display These fields are not populated on this report 329 LUPA 027X All revenue code lines These fields are not populated on this report where the first three
439. nue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 TOTAL 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 TOTAL 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 TOTAL 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 TOTAL 0623 Displays by itself These fields are not populated on this report 329 TOTAL All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 FULL 0023 Does not display These fields are not populated on this report 329 FULL 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 FULL 0274 Displays by itself These fields are not populated on this report 329 FULL 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 FULL 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 FULL 043X All revenue code lines These fields are not populated on this report whe
440. nue codes designated as ancillary 85Z GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 85Z CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 85Z BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 85Z COI NSURANCE The actual coinsurance amount from the paid claim record User Manual February 2009 Version No 2 0 Report Data B 64 Provider Statistical and Reimbursement System Report Type Data Element Description 857 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 857 NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 85Z CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 122 CLAI MS Currently this field has no cost report usage 122 UNITS The number of units applicable to each revenue code 122 CHARGES The charges applicable to each revenue code 122 REV CODE Each revenue code and its associated cover
441. odes 750 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 750 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 750 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 750 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 750 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 750 COINSURANCE The actual coinsurance amount from the paid claim record User Manual February 2009 Version No 2 0 Report Data B 77 Provider Statistical and Reimbursement System Report Type Data Element Description 750 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 750 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 750 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related
442. oes expire you will be prompted to change your password For further assistance contact your CMS help desk Enter your User ID and password and then click Login If you can t remember your password click Forgot your password User ID Password Forgot your password 2 To login to the system enter your registered IACS User ID and Password into the appropriate fields and then click the Login button IACS will validate your credentials If the credentials are valid IACS will log you in For problems related to IACS login accounts CMS has established an External User Services User Manual System Overview and Common Features February 2009 Version No 1 2 1 Provider Statistical and Reimbursement System EUS Help Desk to assist with access to LACS The EUS Help Desk may be reached by E mail at EUSSupport cgi com or by phone at 1 866 484 8049 or TTY TDD at 1 866 523 4759 3 Once logged in to IACS you may request access to the PS amp R system following the instructions in the IACS system 4 Referto Section 3 Performing Tasks in the PS amp R for instructions about using the PS amp R system Note Maximize the size of your browser window so the PS amp R system pages display properly 2 2 Page Layout The PS amp R system utilizes a consistent page layout across all pages This layout is comprised of three primary sections Header The Header area is displayed horizontally across the top of all pages a
443. of units applicable to each revenue code 76P CHARGES The charges applicable to each revenue code 76P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 76P DESCRIPTI ON The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 76P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 76P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 76P OUTLIER The outlier portion of the OPPS payment for the APC 76P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 76P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 76P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 76P COINSURANCE The actual coinsurance amount from the paid claim record 76P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 76P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occ
444. oinsurance amount from the paid claim record 732 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 732 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 732 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 742 CLAIMS Currently this field has no cost report usage 742 UNITS The number of units applicable to each revenue code 742 CHARGES The charges applicable to each revenue code 742 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 742 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 742 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 742 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis User Manual February 2009 Ver
445. on Units Charges Gross Reimb 890 370 00 MSP Cash Deduct 0 00 Mad Days 1 053 Discharge Count 85 TOTAL 36887 5223067697 LESS Beart o Cash Deduct 020 Cak Reimb PIP 0 00 Blood Deduct 020 Actual Cum Pymnts PIP 0 00 Coins 10 34350 Claim interest 162 MS 0 20 Net Remb i852 676 50 Feb 7 2007 30 33626 PM The reports that are generated based on the Inpatient 18x and 21x report template are e Swing Bed SNF MSP LCC 18A e Swing Bed SNF 180 e SNF Inpatient Part A MSP LCC 21A e SNF Inpatient Part A PPS 210 A brief description of these reports is provided in the following sections 4 3 1 Swing Bed SNF MSP LCC 18A The Swing Bed SNF MSP LCC 18A report is a supplemental report to the Swing Bed SNF 180 report The items reported on the Swing Bed SNF MSP LCC 18A report are included on the Medicare Cost Report 4 3 2 Swing Bed SNF 180 The Swing Bed SNF 180 report summarizes swing bed hospital services The items reported on the Swing Bed SNF 180 report are included on the Medicare Cost Report User Manual Inpatient Reports February 2009 Version No 2 0 4 19 Provider Statistical and Reimbursement System 4 3 3 SNF Inpatient Part A MSP LCC 21A The SNF Inpatient Part A MSP LCC 21A report is a supplemental report to the SNF Inpatient Part A PPS 210 report The items reported on the SNF Inpatient Part A MSP LCC 21A report are included on the Medicare
446. ons 058 are rolled up 399 TOTAL 059X All revenue code lines These fields are not normally used where the first three positions 059 are rolled up 399 TOTAL 060X All revenue code lines Part B oxygen charges with outlier where the first three positions 060 are rolled up 399 TOTAL 062X All revenue code lines Part B medical supplies charges with outlier where the first three positions 062 are rolled up 399 TOTAL 0623 Displays by itself Part B surgical dressings charges with outlier 399 TOTAL All other Rev Codes display as All other Part B revenue code charges they come in on the claim they do not roll up 399 TOTAL SERVI CES 399 FULL 0023 Does not display These fields are not populated on this report 399 FULL 027X All revenue code lines Part B medical supplies charges where the first three positions 027 excluding 0274 are rolled up 399 FULL 0274 Displays by itself Part B prosthetics and orthotics charges 399 FULL 029X All revenue codes lines Part B durable medical equipment charges where the first three positions 029 are rolled up 399 FULL 042X All revenue code lines Part B physical therapy count where the first three positions 042 are rolled up 399 FULL 043X All revenue code lines Part B occupational therapy count where the first three positions 043 are rolled up 399 FULL 044X All revenue code lines Part B speech count where the first three positions 044 are
447. ons 062 are rolled up 329 TOTAL 0623 Displays by itself Total Part B Surgical Dressings charges without outlier 329 TOTAL All other Rev Codes display as All other Part B Revenue Code Charges they come in on the claim they do not roll up 329 FULL EPISODES WITHOUT OUTLIER Part B number of Episodes without outlier for full episodes 329 FULL HIPPS REIMBURSEMENT Part B HIPPS Reimbursement without outlier for full episodes WITHOUT OUTLIER 329 FULL EPISODES WITH OUTLIER Part B number of Episodes with outlier for full episodes 329 FULL HIPPS REIMBURSEMENT WITH Part B HIPPS Reimbursement with outlier for full episodes OUTLIER 329 FULL OUTLIER REI MBURSEMENTS Part B outlier reimbursement for full episodes 329 FULL PROSTHETI C ORTHOTIC This is prosthetics and orthotics for full episodes DEVICES 329 FULL DME This is DME for full episodes 329 FULL OXYGEN This is oxygen for full episodes 329 FULL OTHER FEE REIMBURSEMENTS Part B Other Fee for full episodes 329 FULL GROSS REI MBURSEMENT Part B gross reimbursement for full episodes 329 FULL DEDUCTIBLES This is deductibles for Part B 329 FULL COINSURANCE This is coinsurance for Part B 329 FULL NET MSP PAYMENTS This is MSP for Part B 329 FULL MSP RECONCILIATION Net MSP for Part B 329 FULL OTHER ADJUSTMENTS Other adjustments for Part B 329 FULL NET REIMBURSEMENT Net reimbursement for Part B User Manual February 2009 Version No 2 0 Report Data B 112 Provider Sta
448. or Charge MSP LCC and Episodes Summary Report Template Last Page Program ID REDESIGN Paid Dates 01 01 04 THRU 10 01 06 Report Run Date 02 05 07 Provider FYE 12 31 Provider Number 137008 MOBILE NURSE SERVICES COINSURANCE NET MS PAYMENTS MSP RECONCILIATION OTHER ADJUSTMENTS NET REIMBURSEMENT ADDITIONAL INFORMATION SECTION CLAIM INTEREST PAYMENTS Feb 5 2007 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PROVIDER SUMMARY REPORT Page 3 HOME HEALTH PPS PART B EPISODES Report amp 0044228 Report Type 329 SERVICES APPLIED FOR THE PERIODS 01 01 2004 12 31 2004 FULL EPISODES LUPA EPISODES PEP ONLY EPISODES SCIC ONLY EPISODES SCIC WITHIN A PEP TOTAL 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 514 884 25 50 00 51 661 47 0 00 0 00 16 545 72 0 03 0 00 0 00 0 00 0 00 0 03 SERVICES APPLIED FOR THE PERIODS 01 01 2005 12 31 2005 3 9 59 56 AM User Manual February 2009 Version No 2 0 Outpatient Reports 5 42 Provider Statistical and Reimbursement System Exhibit 5 23 Outpatient xxM xx9 Medicare Secondary Payer Lower Cost or Charge MSP LCC and Episodes Payment Reconciliation Detail Report Template PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page Service Month End 09 30 04 HOME HEALTH PPS PART A EPISODES Report 004420
449. or E235 SQLException caught E235 amp arg1 System Error PS amp R Naming Exception Occurred Error E243 NamingException E243 caught during init amp arg1 System Error PS amp R No results found for the FI Error E248 Results do not exist E248 for Fl amp arg1 System Error PS amp R SQL Exception Occurred Error E249 SQLException E249 caught System Error PS amp R No results found for the Load Error E250 Results do not exist E250 Control Main for LCMain for User amp arg1 System Error PS amp R No results found for the Load Error E252 Results do not exist E252 Control Hold for LCHold for User amp arg1 System Error PS amp R No results found for the Load Error E254 Results do not exist E254 Control Release for LCRIse for User amp arg1 System Error PS amp R No results found for the Load Error E256 Results do not exist E256 Control Detail Hold Report for LCDetailHoldReport for User amp arg1 System Error PS amp R SQLException caught Error E257 SQLException caught E257 amp arg1 User Manual February 2009 Version No 2 0 Error Messages C 27 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message ID System Error PS amp R No results found for the Load Error E258 Results do not exist E258 Control Hold History for LCHold History for User amp arg1 System Error PS amp R No results found
450. or ID when working in the PS amp R System User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 4 Provider Statistical and Reimbursement System 3 1 1 Change Contractor ID The Change Contractor ID page provides the user the ability to change the contractor ID for which to generate report requests and view report output Perform the following steps to change the contractor ID 1 Click the Change Contractor ID hyperlink from the User Preferences page The following page appears Help User ID TRTEST17 Contractor Selection Thursday August 23 CNS Provider Statistical amp Reimbursement System User Preferences Contractor Selection Select Contractor ID 14000 14001 T Save Preference Continue 2 Click the radio button corresponding to the contractor with which to work Click the Save Preference check box to set the contractor as the default contractor This contractor is the contractor that you access each time you log in to the PS amp R System 3 Click Continue to proceed to the PS amp R System Home Page User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 5 Provider Statistical and Reimbursement System 3 2 Favorite Requests You can save report requests that you generate frequently as favorite report requests If a favorite report request is saved you can view the parameters of the request and submit new report requests based on
451. or messages are presented in the following table Exhibit C 12 Detail Report Request FI MAC Provider Requests Page Error Messages Form Field User Type Validation Error Message ID FI MAC Provider FI MAC The Your Request Name Error E047 Your Request E047 Requests Your Admin field cannot be null Name is not entered Please Request Name enter a request name to Textbox proceed All This field must not contain Error E152 Request Name E152 special characters V can not contain special lt gt characters V FI MAC Provider FI MAC If the modify button is clicked Error E150 Decline Modify E150 Requests Admin and a part of the report is Comments are required Modify button changed Comments must be entered in the comment field before submission FI MAC Provider FI MAC Comments must be entered in Error E150 Decline Modify E150 Requests Admin the comment field before Comments are required Decline button Decline button can be clicked User Manual February 2009 Version No 2 0 Error Messages C 18 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message ID FI MAC Provider FI MAC If a user wants to change Warning W005 Requests Back Admin providers warning message The Selected Report Types button on the 2 must appear will b
452. or the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 832 CLAIMS Currently this field has no cost report usage 832 UNITS The number of units applicable to each revenue code 832 CHARGES The charges applicable to each revenue code 832 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 832 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes User Manual February 2009 Version No 2 0 Report Data B 72 Provider Statistical and Reimbursement System Report Type Data Element Description 832 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 832 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 832 CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 832 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 832 COINSURANCE The actual coinsurance amount from the paid claim record 832 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this fiel
453. orite request select the Remove Favorite check box corresponding to the favorite request to delete and then click the Remove button at the bottom of the page To refresh the contents of the page click Refresh You can view the details of the favorite request and modify or submit the request by selecting the hyperlink corresponding to the desired favorite request name The resulting page displays details about the report request Click Modify to change the parameters of the report request or Submit to process the User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 6 Provider Statistical and Reimbursement System report using the current report parameters Click Cancel to return to the previous page An example of a summary report request page follows CNS Provider Statistical amp Reimbursement System Site Map Announcements FAQ Help Logout GLOBAL FI MAC 14000 Summary Report Request Home Report Inbox Request Report Favorite Requests Request Summary Request Detail Summary Report Request 6 Confirm Report Request Report Request ID TRTEST17 5 10022 gt Your Request Name ffATESTI7 D 1002T JJ 50 Char Requested Provider s TO0007 Requested Report s 110 115 118 11A 122 125 12P 130 135 134 13P 13Z 140 145 14P No Data Available TODO0007 119 120 124 122 132 142 144 720 725 724 831 832 835 834 83P 83Z 110 DRG Section NOT Requested Format PDF
454. orts are e 998 Consolidation of Outpatient Claims Excluding MSP LCC e 1000 Consolidated Summary of All Report Types This chapter provides an overview of the consolidation reports available in the PS amp R System Chapter 4 Inpatient Reports provides a description of the inpatient reports available in the PS amp R System Chapter 5 Outpatient Reports provides a description of the outpatient reports available in the PS amp R System See Appendix B Report Data for a definition of the data elements available on reports 6 1 998 Consolidation of Outpatient Claims Excluding MSP LCC The 998 Consolidation of Outpatient Claims Excluding MSP LCC report can be produced for any provider to consolidate all outpatient claims that have the potential to be presented on different report types except MSP LCC claims This report is generated in detail format only No summary format is available This report is divided into Claim Information Reimbursements and Additional Information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The 998 Consolidation of Outpatient Claims Excluding MSP LCC report claim information section contains patient information such as the patient name DCN Gross Reimbursement Deductibles Line Item Reimbursement subtotals for the re
455. orts that are generated based on the outpatient xx5 Fee Reimbursed report template are Inpatient Part B Fee Reimbursed 125 Outpatient Fee Reimbursed 135 e Outpatient Other Fee Reimbursed 145 e SNF Inpatient Fee Reimbursed 225 e SNF Outpatient Fee Reimbursed 235 Home Health Part B Fee Reimbursed 345 Federally Qualified Health Center Fee Reimbursed 735 Rehabilitation Facility Fee Reimbursed 745 Comprehensive Outpatient Rehabilitation Facilities Fee Reimbursed 755 Community Mental Health Center Fee Reimbursed 765 e ASC and ASC Fee Schedule Fee Reimbursed 835 Critical Access Hospital Fee Reimbursed 855 Additional Information MS Cash Deduct 000 MS Blood Deduct 000 MS Coins 000 Claim interest 000 Additional Information MS Cash Deduct 000 MS Blood Deduct 000 MS Coins 000 Claim interest 000 12 338 54 PM User Manual February 2009 Version No 2 0 Outpatient Reports 5 32 Provider Statistical and Reimbursement System A brief description of these reports is provided in the following sections 5 7 1 Inpatient Part B Fee Reimbursed 125 The Inpatient Part B Fee Reimbursed 125 report shows covered charges and reimbursement by revenue code for fee reimbursed services for patients who have exhausted Part A benefits The items reported on the Inpatient Part B Fee Reimbursed 125 report are not to be included on the Medicare
456. ot populated on this report 339 LUPA 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 LUPA 0274 Displays by itself These fields are not populated on this report 339 LUPA 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 128 Provider Statistical and Reimbursement System Report Type Data Element Description 339 LUPA 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 LUPA 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 LUPA 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 LUPA 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 LUPA 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 LUPA 057X All revenue code lines These fields are not populated on this report where the first three posit
457. ould be selected continue Incorrect Output All When the incorrect output Error E169 Output Formatis E169 Format Selected format is selected not PDF or CSV C 6 Summary Report Request Report Request Confirmation The Summary Report Request Report Request Confirmation page error messages are presented in the following table Exhibit C 6 Summary Report Request Report Request Confirmation Page Error Messages Form Field User Type Validation Error Message ID User Manual February 2009 Version No 2 0 Error Messages C 9 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message ID Exclude CMS At least one provider s Error E311 At least one E311 Checkbox FI MAC Exclude checkbox must not provider s Exclude checkbox Parent be selected must not be selected Provider Your Request All The Your Request Name Error E047 Your Request E047 Name Field field cannot be null Name is not entered Please enter a request name to proceed All This field can only contain Error E152 Request Name E152 alpha numeric characters and can only contain alpha the following special numeric characters and the characters _ following special characters No Data Available All The number of reports Error E315 The request will E315 generated must be greater not generate any reports than zero Save Request as All The Favorite Name
458. outlier for LUPA WITHOUT OUTLIER 399 LUPA EPISODES WITH OUTLIER Part B of Episodes with outlier for LUPA 399 LUPA HIPPS REIMBURSEMENT WITH Part B HI PPS reimbursement with outlier for LUPA OUTLIER 399 LUPA OUTLIER REI MBURSEMENTS Part B outlier reimbursement for LUPA 399 LUPA PROSTHETI C ORTHOTI C Part B P amp O for LUPA DEVICES 399 LUPA DME Part B DME for LUPA 399 LUPA OXYGEN Part B Oxygen for LUPA 399 LUPA OTHER FEE REIMBURSEMENTS Part B Other Fee for LUPA 399 LUPA GROSS REIMBURSEMENT Part B gross reimbursement for LUPA 399 LUPA DEDUCTIBLES Part B deductible for LUPA 399 LUPA COINSURANCE Part B coinsurance for LUPA 399 LUPA NET MSP PAYMENTS Part B MSP Recon for LUPA 399 LUPA MSP RECONCILIATION Part B Net MSP Payment for LUPA 399 LUPA OTHER ADJUSTMENTS Part B Other Adjust for LUPA 399 LUPA NET REIMBURSEMENT Part B net reimbursement for LUPA 399 LUPA CLAIM INTEREST PAYMENTS Part B claim interest payments for LUPA 399 PEP EPISODES WITHOUT OUTLIER Part B of Episodes w o outlier for PEP 399 PEP HIPPS REIMBURSEMENT WITHOUT Part B HIPPS reimbursement without outlier for PEP OUTLIER 399 PEP EPISODES WITH OUTLIER Part B of Episodes with outlier for PEP 399 PEP HIPPS REIMBURSEMENT WITH Part B HI PPS reimbursement with outlier for PEP OUTLIER 399 PEP OUTLIER REIMBURSEMENTS Part B outlier reimbursement for PEP 399 PEP PROSTHETIC ORTHOTIC DEVICES Part B P amp O for PEP 399 PEP DME Part B DME for PEP
459. p R An Action object must derive Error E299 An Action object E299 from AbstractAction class must be of type org brw air control AbstractAction System Error PS amp R Exception occurred in the Error E300 E300 FrontController getAction FrontController getAction method amp arg1 System Error PS amp R Please specify the input file Error E301 XML input file path E301 path for the XML file was null or blank System Error PS amp R An action must be specified Error E302 Action is null E302 System Error PS amp R An action has an invalid Error E303 An action has an E303 format invalid format current amp arg1 and Class amp arg2 System Error PS amp R I O Exception occurred while Error E304 IO Exception reading E304 reading the Application Properties file the Application properties file User Manual February 2009 Version No 2 0 Error Messages C 28 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message ID System Error PS amp R Cannot find the Application Error E305 Application properties E305 Properties File file not found System Error PS amp R Login Credentials do not Error E327 Invalid PSR User E327 belong to a PSR User Group Please call Help Desk System Error PS amp R Logged in user has an invalid Error E328 PSR User does not E328 Organization ID in his her have a valid Organization ID profile Please call Help Desk System
460. parts of Medicaid The Centers for Medicare and Medicaid Services CMS responsibilities include managing contractor claims payment fiscal audit and or overpayment prevention and recovery developing and monitoring payment safeguards necessary to detect and respond to payment errors or abusive patterns of service delivery CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets health identifiers and security standards CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set Certificate of Medical Necessity CMN A form required by Medicare that allows you to use certain durable medical equipment prescribed by your doctor or one of the doctor s office staff Comma Separated Values CSV The comma separated values file format is a file type that stores tabular data like in an Excel spreadsheet The file contains fields columns separated by the comma character and records rows separated by new lines Fields that contain a special character comma new line or double quote must be enclosed in double quotes However if a line contains a single entry that is the empty string it may be enclosed in double quotes If a field s value contains a double quote character it is escaped by placing another double quote character next to it The CSV file format does not require a specific character encoding byte order or line terminator fo
461. pathology services Contractors Private health insurers or private organizations that contracted by CMS to provide various services including processing and paying Medicare claims and or bills and performing other claim related activities such as medical review and fraud investigations Continuing Care Retirement Community CCRC A housing community that provides different levels of care based on what each resident needs over time This is sometimes called life care and can range from independent living in an apartment to assisted living to full time care in a nursing home Residents move from one setting to another based on their needs but continue to live as part of the community Care in CCRCs is usually expensive Generally CCRCs require a large payment before you move in and charge monthly fees Cost Report An annual report submitted by all institutional providers participating in the Medicare program The report is submitted on prescribed forms depending on the type of provider for example hospital skilled nursing facility etc The cost information and statistical data reported must be current accurate and in sufficient detail to support an accurate determination of payments made for the services rendered The cost report contains provider information such as facility characteristics utilization data and financial statement data CMS maintains the cost report data in the Healthcare Provider Cost Reporting
462. patient xxP Outpatient Prospective Payment System OPPS Provider Summary Report Template First Page PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PROVIDER SUMMARY REPORT Page 1 Paid Dates 02 01 04 THRU 10 01 06 OUTPATIENT OPPS Report 0042203 Report Run Date 02 01 07 Report Type 13F Provider FYE 12 31 Provider Number T00007 PETERBORO GENERAL HOSPITAL SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD SERVICES FOR PERIOD 01 01 04 12 31 04 No Data Requested No Data Requested No Data Requested STATISTIC SECTION CLAIMS 10 CHARGE SECTION REV CODE DESCRIPTION UNITS CHARGES UNITS CHARGES UNITS CHARGES UNITS CHARGES 0251 DRUGS GENERIC 3 2677 0252 DRUGS NONGENERIC 15 225 36 0254 DRUGS INCIDENT ODX 0 0 00 0255 DRUGS INCIDENT RAD 0 0 00 0258 IV SOLUTIONS 0 0 00 0260 IV THERAPY 1 5257 00 0272 STERILE SUPPLY 0 0 00 0320 DX X RAY 1 5207 00 0324 DX X RAY CHEST 3 585 00 0351 CT SCAN HEAD 1 1 054 00 0352 CT SCAN BODY 0 0 00 0402 ULTRASOUND 0 0 00 im 0410 RESPIRATORY SVC 0 0 00 0450 EMERG ROOM 10 4 039 00 0610 MRT 0 0 00 0636 DRUGS DETAIL CODE 24 23 893 50 0710 RECOVERY ROOM 1 5157 00 0730 EKG ECG 3 5570 00 0761 TREATMENT RM 15 1 519 00 0762 OBSERVATION RM 2 1 606 00 0921 PERI VASCUL LAB 0 0 00 TOTAL COVERED CHARGES 95 14 169 63 REIMBURSEMENT SECTION Feb 1 2007 1 7 57 38 PM User Manual Outpatient Reports February 2009 Version No 2 0 5 16 Provider Statistical and Rei
463. payments such as bi weekly pass through payments lump sums and financial adjustments etc 810 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 81A MEDICARE DAYS Currently this field has no cost report usage 81A CLAIMS Currently this field has no cost report usage 81A TOTAL UNDUPLICATED CENSUS The unduplicated census count of the hospice for all patients COUNT initially admitted and filing an election within the reporting period 81A UNDUP DAYS Currently this field has no cost report usage 81A HOURS The number of hours applicable to this revenue code 81A UNITS REV CODE 0651 The number of units applicable to each revenue code 81A UNITS REV CODE 0652 The number of hours applicable to this revenue code 81A UNITS REV CODE 0655 The number of units applicable to each revenue code 81A UNITS REV CODE 0656 The number of units applicable to each revenue code 81A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 81A DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 81A TOTAL COVERED CHARGES All Medicare covered charges associated with
464. per discharge exception interim payment for capital related costs that qualifying hospitals are entitled to receive in accordance with Medicare payment policy 11T TOTAL CAPITAL PAYMENTS This is the sum of the capital amounts for HSP FSP outlier hold harmless disproportionate share adjustment indirect medical education and exception payments 11T GROSS REIMBURSEMENT This amount is the sum of total operating and total capital payments 11T DEVICE CREDIT This amount represents the credit that a provider received to replace a medical device that may have been defective or under warranty This amount can be identified with a value code of FD on the claim User Manual February 2009 Version No 2 0 Report Data B 22 Provider Statistical and Reimbursement System Report Type Data Element Description 11T CASH DEDUCTIBLE The sum of actual cash deductible amount from the paid claim records 11T BLOOD DEDUCTIBLE The sum of actual blood deductible amount from the paid claim records 11T COINSURANCE The sum of actual coinsurance amount from the paid claim records 11T NET MSP PAYMENTS The sum of net payments made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 11T MSP PASS THRU RECONCILIATION This field is info
465. plete listing and a description of all revenue codes 135 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 135 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 135 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 135 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 135 COINSURANCE The actual coinsurance amount from the paid claim record 135 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 135 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 135 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 145 CLAIMS Currently this field has no cost report usage 145 UNITS The number of units applicable to each revenue code User Manual February 2009 Version No 2 0 Report Data B 80 Provider Statistical and Reimbursement System Report Type Data Elem
466. port 329 SCIC 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 SCIC 0274 Displays by itself These fields are not populated on this report 329 SCIC 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 SCIC 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 SCIC 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 SCIC 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 SCIC 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 110 Provider Statistical and Reimbursement System Report Type Data Element Description 329 SCIC 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 SCIC 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rol
467. port where the first three positions 055 are rolled up 339 SCIC 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 SCIC 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 339 SCIC 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 339 SCIC 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 SCIC 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 SCIC 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 SCIC 0623 Displays by itself These fields are not populated on this report 339 SCIC All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 339 TOTAL 0023 Does not display These fields are not populated on this report 339 TOTAL 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 TOTAL 0274 Displays by itself These fields are not populated on this report 339
468. port Data B 156 Provider Statistical and Reimbursement System Report Type Data Element Description 399 SCIC PEP 057X All revenue code lines Total covered charges related to home health aide serv during where the first three positions 057 SCIC PEP episode are rolled up 399 SCIC PEP 058X All revenue code lines Part B other visits without outlier where the first three positions 058 are rolled up 399 SCIC PEP 059X All revenue code lines Total visit covered charges for various disciplines for SCIC PEP where the first three positions 059 episode are rolled up 399 SCIC PEP 060X All revenue code lines Part B oxygen charges where the first three positions 060 are rolled up 399 SCIC PEP 062X All revenue code lines Part B medical supplies charges where the first three positions 062 are rolled up 399 SCIC PEP 0623 Displays by itself Part B surgical dressings charges 399 SCIC PEP All other Rev Codes display All other Part B revenue code charges as they come in on the claim they do not roll up 399 SCIC 0023 Does not display These fields are not populated on this report 399 SCIC 027X All revenue code lines Part B med supplies charges where the first three positions 027 excluding 0274 are rolled up 399 SCIC 0274 Displays by itself Part B prosthetics and orthotics charges 399 SCIC 029X All revenue codes lines Part B d
469. port are adjusted by the Medicare Secondary Payer Lower Cost or Charge MSP LCC amounts The items reported on the Inpatient Part A MSP LCC 11A report are included on the Medicare Cost Report 4 2 3 Inpatient Long Term Care Part A PPS Interim Bills 11T The Inpatient Long Term Care Part A PPS Interim Bills 11T report summarizes inpatient long term care Part A services that have been billed on and interim basis that is a bill frequency code of 2 or 3 The items reported on the Inpatient Long Term Care Part A PPS Interim Bills 11T report are not to be included on the Medicare Cost Report 4 2 4 Inpatient Long Term Care Part A PPS 11S The Inpatient Long Term Care Part A PPS 11S report summarizes Inpatient long term care Part A services The items reported on the Long Term Care Part A PPS 115 report are included on the Medicare Cost Report User Manual Inpatient Reports February 2009 Version No 2 0 4 13 Provider Statistical and Reimbursement System 4 2 5 Inpatient Rehabilitation PPS Interim Bills 11K The Inpatient Rehabilitation PPS Interim Bills 11K report summarizes Inpatient Part A hospital services reimbursed under the Inpatient Rehabilitation Facility PPS payment system that have been billed on an interim basis that is a bill frequency code of 2 or 3 The items reported on the Inpatient Rehabilitation PPS Interim Bills 11K report are not to be included on the Medicare Cost Report 4
470. ports and the charges for the revenue codes The reimbursements section shows how Net Reimbursement is calculated The additional information section shows claim interest total gross fee schedule deductibles and coinsurance The report also provides a monthly totals section that sums the information from the sections above An example of the 998 Consolidation of Outpatient Claims Excluding MSP LCC report follows User Manual Consolidation Reports February 2009 Version No 2 0 6 1 Provider Statistical and Reimbursement System Exhibit 6 1 998 Consolidation of Outpatient Claims Excluding MSP LCC Report PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page 1 Service Month End 02 29 04 CONSOLIDATION OF OUTPATIENT CLAIMS EXCLUDING MSP LCC Report 8 0044202 Report Run Date 02 21 07 Report Type 998 Provider FYE 12 31 Paid Dates 01 01 80 to 10 01 06 Provider Number 100007 PETERBORO GENERAL HOSPITAL ZT o i rin Pant Nire WHLR BM Frege Rev Gross MSP tSRDR cn Pye Line tem mer Gross Reimb 2388 35 MSP Deductibles 0 00 DC 20438699452205 Trans Type Code MPS Unts Chamet Qu Deduciibles Coins MSP mon NewkPymes Rad Remb C nepot Outer 020 MSP Coins 000 Pint Catrik 000000000000 Processor ID 14000 ao Aasi 1 9650520 92 3064 0 00 051 12 0 00 S0 0 na 1 Less Claim interest 0 00 Med Rerd 000791940726 Zip Code 32708 540 ADAM 162
471. positions 027 excluding 0274 are rolled up 329 LUPA 0274 Displays by itself These fields are not populated on this report 329 LUPA 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 LUPA 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 LUPA 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 LUPA 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 LUPA 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 95 Provider Statistical and Reimbursement System Report Type Data Element Description 329 LUPA 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 LUPA 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 LUPA 058X All revenue code lines These fields are not populated on this report where the first th
472. positions 062 are rolled up 399 PEP 0623 Displays by itself Part B Surgical Dressings charges with outlier 399 PEP All other Rev Codes display as All other Part B Revenue Code Charges they come in on the claim they do not roll up 399 SCIC PEP 0023 Does not display These fields are not populated on this report 399 SCIC PEP 027X All revenue code lines Part B Med Supplies charges with outlier where the first three positions 027 excluding 0274 are rolled up 399 SCIC PEP 0274 Displays by itself Part B Prosthetics and Orthotics charges with outlier 399 SCIC PEP 029X All revenue codes Part B Durable Med Equip charges with outlier lines where the first three positions 029 are rolled up 399 SCIC PEP 042X All revenue code lines Total Part A and Part B occupational therapy visit count during where the first three positions 042 SCIC PEP episode are rolled up 399 SCIC PEP 043X All revenue code lines Total Part A and Part B occupational therapy visit count during where the first three positions 043 SCIC PEP episode are rolled up 399 SCIC PEP 044X All revenue code lines Total Part A and Part B speech therapy visit count during where the first three positions 044 SCIC PEP episode are rolled up 399 SCIC PEP 055X All revenue code lines Total Part A and Part B visit count related to nursing services where the first three positions 055 during SCIC PEP episode are rolled up 399 SCIC PEP
473. printed document as an electronic image that you can view navigate print or forward to someone else PDF files are created using Adobe Acrobat Acrobat Capture or similar products To view and use the files you need the free Acrobat Reader which you can easily download Once you have downloaded the Reader it will start automatically whenever you want to look at a PDF file Quality Improvement Organization QIO A group of clinicians doctors paid under contract with the federal government to review the medical care given to Medicare patients by other doctors and hospitals RAP Request for Anticipation of Payment Regional Home Health Intermediary RHHI A private company that contracts with Medicare to pay home health bills and check on the quality of home health care Renal Transplant A hospital unit that is approved to furnish transplantation and other medical and Center surgical specialty services directly for the care of End Stage Renal Disease transplant patients including inpatient dialysis furnished directly or under arrangement RUG Resource Utilization Group Rural Health Center An outpatient facility that is primarily engaged in furnishing physicians and other medical and health services and that meets other requirements designated to ensure the health and safety of individuals served by the clinic The clinic must be located in a medically under served area that is not urbanized as defined b
474. pter 25 Section 60 4 for a complete listing of revenue codes 74A DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 74A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 74A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis User Manual February 2009 Version No 2 0 Report Data B 41 Provider Statistical and Reimbursement System Report Type Data Element Description 74A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 74A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 74A COI NSURANCE The actual coinsurance amount from the paid claim record 74A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 74A NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 74A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 10
475. r Cost Reimbursed 140 SNF Inpatient Part B Cost Reimbursed 220 User Manual Outpatient Reports February 2009 Version No 2 0 5 2 Provider Statistical and Reimbursement System e SNF Outpatient Cost Reimbursed 230 Home Health Part B 340 Clinic Rural Health 710 e Federally Qualified Health Center 730 Rehabilitation Facility 740 Comprehensive Outpatient Rehabilitation Facilities 750 Community Mental Health Center 760 e Critical Access Hospital 850 xxM xx9 Home Health Agency MSP LCC Episodes Report Template Home Health PPS Part A MSP LCC 32M Home Health PPS Part B Episodes 329 Home Health Part A MSP LCC 33M Home Health PPS Part A Episodes 339 Home Health PPS Part A and Part B Episodes 399 322 332 Home Health Agency RAP Report Template Home Health PPS Part B RAP 322 Home Health PPS Part A RAP 332 81x 82x Hospice Report Template Hospice Non Hospital Based MSP LCC 81A e Hospice Non Hospital Based 810 e Hospice Hospital Based MSP LCC 82A Hospice Hospital Based 820 e 831 ASC and ASC Fee Schedule After 12 90 With the exception of xxA report templates Outpatient reports display data at the line level for claims received in the Paid Claims files received from the Fiscal Intermediary Standard System FISS The xxA Outpatient reports display data at the claim level This chapter provides an overview of the seque
476. r SCIC 329 SCIC HIPPS REIMBURSEMENT This is Part B number of episodes without outlier for SCIC WITHOUT OUTLIER only 329 SCIC EPISODES WITH OUTLIER This is Part B HHPPS reimbursement without outlier for SCIC only 329 SCIC HIPPS REIMBURSEMENT WITH This is Part B number of episodes with outlier for SCIC only OUTLIER 329 SCIC OUTLIER REIMBURSEMENTS This is Part B HHPPS reimbursement with outlier for SCIC only 329 SCIC PROSTHETIC ORTHOTIC This is Part B outlier reimbursement for SCIC only DEVICES 329 SCIC DME This is Part B P amp O for SCIC only 329 SCIC OXYGEN This is Part B DME for SCIC only 329 SCIC OTHER FEE REI MBURSEMENTS This is Part B oxygen for SCIC only 329 SCIC GROSS REI MBURSEMENT This is Part B other fee SCIC only User Manual February 2009 Version No 2 0 Report Data B 114 Provider Statistical and Reimbursement System Report Type Data Element Description 329 SCIC DEDUCTIBLES Part B deductibles for SCIC 329 SCIC COINSURANCE This is Part B deductibles for SCIC only 329 SCIC NET MSP PAYMENTS This is Part B coinsurance for SCIC only 329 SCIC MSP RECONCILIATION This is Part B MSP reconciliation for SCIC only 329 SCIC OTHER ADJUSTMENTS This is Part B net MSP payment for SCIC only 329 SCIC NET REIMBURSEMENT This is Part B other adjustments for SCIC only 329 SCIC CLAIM INTEREST PAYMENTS This is
477. r Statistical and Reimbursement System ID Form Field User Type Validation Error Message E330 Selection of the All If the PDF selected request Error E330 This request PDF Format and results in a PDF file which is exceeds the maximum then clicking over the allowable PDF file allowable PDF file size for Continue size and then clicks Provider s providers Continue which exceed pdf file size limitations inserted here separated by commas Please select CSV or change request parameters E331 Illegal Character Valid for the All non alpha numeric Error E331 Security Security Error entire PS amp R characters excluding the Exception encountered system following characters Please call Help Desk excluding the 1G cT tat Your Request brow on Name fied of 7 the 22 Confirmation E LE Screens Neu OE Please refer to will generate a security Error E152 for error documentation relating to the Your Request Name field E331 Login Security PS amp R A security exception was Security Exception encountered encountered Please call Help Desk E385 Detailed Load Control CMS FI Mac If the user selects PDF as a Error E385 This request Report Request PDF report format and the page exceeds the maximum Size Limitation limit exceeds 500 allowable PDF file size Please select CSV or change request parameters wool Service Period From All Entry is one day greater than Warning You have W002
478. r click Back to return to the previous page The following page appears if you click Continue Cs Provider Statistical amp Reimbursement System Site Map h Announcements OO ikele Ne GLOBAL FI MAC User ID STRTI S Thursday Augus Summary Report Request ursday Augu Home Report Inbox Request Report Favorite Requests Request Summary Request Detail Summary Report Request 3 Select Service Periods Default is Provider FYE at 1 Year Intervals Format MM DD YYYY Update Service Dates by Interval Interval Year x Period 1 Start Date l Esj Apply Update Service Dates by Period Period 1 Period 2 Period 3 Period 4 From E From Es From Es From E Apply To Eg To l Eg To Es To Eg Update Service Dates by Provider s BARU 10 Period 1 Period 2 Period 3 Period 4 Saal Exclude Exclude Exclude Exclude IT75237 From 0170172006 FE From 01 01 2007 From 01 01 2008 From 01 01 2009 FYE 0930 Es 12 31 2007 r To fi 2 31 2008 r ITo fi 2 31 2009 E O ro 12 31 2006 4 Select Paid Dates Include all Paid Dates available at time of report generation C From 1701 2005 E To Back Continue Reset 6 Select the service periods and claim paid dates to include in the report s You can specify the service period by selecting the interval and period start date and applying these date ranges to all providers and periods by s
479. r obtains a Provider Agreement with Medicare and a Fiscal Intermediary Medicare Administrative Contractor is assigned that provider is said to be active for that Fiscal Intermediary Medicare Administrative Contractor When the provider is terminated from Medicare or is assigned to a different FI MAC the provider is said to be inactive for that FI MAC any provider that is inactive for an FI MAC is one that the FI MAC serviced previously but no longer services User Manual February 2009 Version No 2 0 D 4 Glossary Provider Statistical and Reimbursement System Term Definition Incentive Reward Program IRP An incentive reward program established in order to encourage individuals to report information on individuals and entities that are engaged in or have engaged in acts or omissions that constitute grounds for the imposition of a sanction under 881128 1128A or 1128B of the Act or who have otherwise engaged in sanctionable fraud and abuse against the Medicare program under title XVIII of the Social Security Act Inpatient Services Health care that you get when you are admitted to a hospital Inpatient A person who has been admitted at least overnight to a hospital or other health facility for the purpose of receiving a diagnosis treatment or other health service International Classification of Diseases ICD 9 A national coding method to enable providers to effectively document the m
480. r priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 235 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 235 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions User Manual February 2009 Version No 2 0 Report Data B 82 Provider Statistical and Reimbursement System Report Type Data Element Description 345 CLAIMS Currently this field has no cost report usage 345 UNITS The number of units applicable to each revenue code 345 CHARGES The charges applicable to each revenue code 345 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 345 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 345 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancilla
481. r the report request in or Phone can be up to ten 10 digits E mail Required Type the e mail address of the primary contact for the report request in the format recipient name Q9 domain qualifier for example john doe cms gov where recipient name gt is john doe domain is cms and qualifier is gov Fax Optional Type the fax number of the primary contact for the report request in or Fax can be up to ten 10 digits Reason for Request Required Type the reason for the request to include with the report request Reason for Request can be up to 250 characters Secondary First Name Optional Type the first name of the secondary contact for the report request Last Name Optional Type the last name of the secondary contact for the report request Phone Optional Type the telephone number of the secondary contact for the report request in or Phone can be up to ten 10 digits E mail Optional Type the e mail address of the primary contact for the report request in the format recipient name gt lt domain gt lt dqualifier gt for example john doe cms gov where recipient name gt is john doe domain is cms and qualifier is gov Fax Optional Type the fax number of the secondary contact for the report request in or Fax can be up to ten 10 digits Reason for Request Optiona
482. r type s and FYE date Error E101 No providers of E101 Parent Provider FI MAC selected must have at least the selected Provider Type s users only or By Parent one applicable provider are applicable Provider Type Provider and Filter by FYE Date Checkbox Filter by FYE FI MAC If box is checked a month Error E081 Filter by FYE E081 Date Checkbox Parent must be selected from the Date chosen but month not Provider Month drop down menu selected Filter by FYE FI MAC The day selected must be in Error E310 date is not a E310 Date Checkbox Parent the month selected valid date Day Drop Down Provider Menu User Manual February 2009 Version No 2 0 Error Messages C 2 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message ID By Provider CMS If radio button is clicked at Error E025 No provider E025 Number Radio FI MAC least one provider number number s were chosen Button Parent must be selected Froviger If By Provider Type within Error E024 Please select E024 Contractor CMS users only provider s or By Provider Type or All Providers Parent Provider users only radio button is not clicked this radio button must be clicked All Providers Parent If By Provider Type or By Error E024 Please select E024 Provider Provider Number radio button provider s is not
483. ractor each time you log in to the PS amp R System Click Continue to proceed to the PS amp R System Home Page To change the default contractor select the Change Contractor ID hyperlink from the User Preferences page to return to this page The following page appears when you log in to the PS amp R System for the first time CNS Provider Statistical amp Reimbursement System Help Logo User ID TRTE Contractor Selection Thursday August 23 User Preferences Contractor Selection Select Contractor ID 14000 C 14001 T Save Preference Continue The options available from the menu are e Home e User Preferences e Report Inbox e Summary Report Inbox e Detail Report Inbox User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 2 Provider Statistical and Reimbursement System e Request Report Favorite Requests Request Summary Request Detail The high level steps that are performed to request summary and detail reports and to view the report output are 1 Select provider s to include in the report s Select report s to generate Select service periods for the report s Select paid dates for the report s Select the report format Type the name to assign to the request optional and submit the request B Nw EB op m Check the report status and view the report output The following sections provide the steps to e Request a summary report e Request a detail report e
484. rd amp HE Num Recpt Dt Paid Dt Service From Service Thru MADAR 20408527757804 D0 DOCIECOW 181000000000 0937611464 04 27 04 0U31 04 MADAR 001000000000 181000000000 0937611454 Oro ooa 0U31 04 2 04 04 Monthly Totals for PETERBORO GENERAL HOSPITAL for service month end 2 29 04 Feb 7 2007 Bu Freg 7 RewCode HCPCS Units Charges HCPCS Remb Trans Type D 0636 Q2022 195 40 012 05 18525 Processor ID 14000 TOTAL 195 4001205 8525 Bil Freg 5 RewCode HCPCS Units Charges HCPCS Remb Trans Type c 0635 Q2022 155 32 003 64 148 20 Processor ID 14000 TOTAL 155 SI2 00964 14820 Units Charges HCPCS Reimb TOTAL 39 8 002 41 SING 2n Gross Reimb LESS Cast Deduct Blood Deduct Coins MSP Net Remb Gross Reimb Less Cast Deduct Blood Deduct Coins MSP Net Remb Gross Reimb Cas Dedect Blood Deduct Coins Net Remb 18525 0 00 0 00 0 00 2000 uggs 14820 0 00 0 00 0 00 uo 514820 3705 000 000 000 000 33705 Page 1 Report OD44202 Report Type 115 Paid Dates 01 01 04 to 10 01 06 Additional Information MS Cash Deduct 0 00 MS Blood Deduct 0 00 MS Coins 0 00 Claim interest 0 00 Claim Report Spits nans MS Cash Deduct 000 MS Blood Deduct 0 00 MS Coins 0 00 Claim interest 000 Claim Report Spits nans Additional information MS Cash Dedect s020 MS Blood Deduct bulan MS Coins 0
485. re days and the number of claims being reported for each of the reporting periods The charge section displays the number of units and the total dollar amount of the revenue code being reported The reimbursement section displays operating capital and gross reimbursement amounts for the reporting period such as hospital and federal specific outlier DSH LIP IME teaching adjustments new technology IPF ECT hold harmless and exception amounts This section also provides total operating payments total capital payments and net reimbursement totals for each of the reporting periods included in the report The Payment section displays gross distribution less device credit cash deductible blood deductible coinsurance net MSP payments MSP pass thru reconciliation other adjustments and the net reimbursement The Additional Information Section displays the calculated net reimbursement for PIP actual claim payments for PIP claim interest payments IRF penalties LTCH short stay outlier payments CAP Federal specific at 100 CAP outlier at 100 discharges DRG CMG weight case mix index User Manual Inpatient Reports February 2009 Version No 2 0 4 4 Provider Statistical and Reimbursement System trans adjusted discharges trans adjusted DRG CMG weight and trans adjusted case mix index for each of the reporting periods included in the report If the Include 110 DRG Section option is selected when the report is generated the DRG Sectio
486. re Cost Report 5 11 4 Hospice Hospital Based 820 The Hospice Hospital Based 820 report summarizes the hospital provider based Hospice claim data The items reported on the Hospice Hospital Based 820 report are included on the Medicare Cost Report 5 12 831 ASC and ASC Fee Schedule After 12 90 The 831 ASC and ASC Fee Schedule After 12 90 Provider Summary report displays summary statistic charge reimbursement and additional information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The data displayed in each section is determined by the report selected for generation The statistic section shows the claims for each reporting period The charge section displays the number of units and the total dollar amount of the revenue code being reported The reimbursement section displays how Net Reimbursement is calculated Finally the additional information section displays the claim interest payments and the standard overhead amount The 831 ASC and ASC Fee Schedule After 12 90 Payment Reconciliation detail report is divided into Claim Information Reimbursements and Additional Information sections The claim information section displays patient information such as the patient name DCN Standard Overhead Amount Blood Deductible Line Item
487. re covered charges associated with revenue codes designated as ancillary 83A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 83A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 83A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 83A COINSURANCE The actual coinsurance amount from the paid claim record 83A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 83A NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 83A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 85A CLAI MS Currently this field has no cost report usage 85A UNITS The number of units applicable to each revenue code 85A CHARGES The charges applicable to each revenue code 85A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 85A DESCRIPTION The description of each revenue code and its associated covered units and cha
488. re included on the Medicare Cost Report 5 5 6 Critical Access Hospital Ambulance Blend Effective 04 01 02 85Z The Critical Access Hospital Ambulance Blend Effective 04 01 02 85Z report summarizes critical access hospital outpatient ambulance services reimbursed under the fee schedule blended payment which is effective for services provided on or after April 1 2002 The items reported on the Critical Access Hospital Ambulance Blend Effective 04 01 02 85Z report are included on the Medicare Cost Report 5 6 xx2 Vaccines Report Template The xx2 Outpatient Vaccines Provider Summary report template displays summary statistic charge reimbursement and additional information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The data displayed in each section is determined by the report selected for generation The statistic section shows the number of claims for each reporting period The charge section displays the number of units and the total dollar amount of the revenue code being reported The reimbursement section displays how Net Reimbursement is calculated Finally the additional information section displays the claim interest payments The xx2 Outpatient Vaccines Payment Reconciliation detail report template is divided into claim
489. re rolled up 399 PEP 044X All revenue code lines Total Part A and Part B speech therapy visit count during PEP where the first three positions 044 episode are rolled up 399 PEP 055X All revenue code lines Total Part A and Part B visit count related to nursing services where the first three positions 055 during PEP episode are rolled up 399 PEP 056X All revenue code lines Total Part A and Part B visit count related to med soc serv where the first three positions 056 are rolled up during PEP episode User Manual February 2009 Version No 2 0 Report Data B 143 Provider Statistical and Reimbursement System Report Type Data Element Description 399 PEP 057X All revenue code lines Total Part A and Part B visit count related to home health aide where the first three positions 057 serv during PEP episode are rolled up 399 PEP 058X All revenue code lines Part B Other Visits with outlier where the first three positions 058 are rolled up 399 PEP 059X All revenue code lines Total Part A and Part B visit count for all disciplines for PEP where the first three positions 059 episodes are rolled up 399 PEP 060X All revenue code lines Part B Oxygen charges with outlier where the first three positions 060 are rolled up 399 PEP 062X All revenue code lines Part B Med Supplies charges with outlier where the first three
490. re the first three positions 043 are rolled up 329 FULL 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 FULL 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 106 Provider Statistical and Reimbursement System Report Type Data Element Description 329 FULL 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 FULL 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 FULL 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 FULL 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 FULL 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 FULL 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 FULL 0623 Displays by itself These fi
491. re the first three positions 059 are rolled up 339 TOTAL 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 TOTAL 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 TOTAL 0623 Displays by itself These fields are not populated on this report 339 TOTAL All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 339 FULL 0023 Does not display These fields are not populated on this report 339 FULL 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 FULL 0274 Displays by itself These fields are not populated on this report 339 FULL 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 127 Provider Statistical and Reimbursement System Report Type Data Element Description 339 FULL 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 FULL 043X All revenue code lines These fields are not populated on
492. reatment Cond Code 73 type 720 AVG PYMT RATE Rev Code 821 The average composite rate reimbursement by treatment Cond Code 74 type 720 AVG PYMT RATE Rev Code 821 The average composite rate reimbursement by treatment Cond Code 76 type 720 AVG PYMT RATE Rev Code 831 The average composite rate reimbursement by treatment Cond Code 71 type 720 AVG PYMT RATE Rev Code 831 The average composite rate reimbursement by treatment Cond Code 72 type 720 AVG PYMT RATE Rev Code 831 The average composite rate reimbursement by treatment Cond Code 73 type User Manual February 2009 Version No 2 0 Report Data B 87 Provider Statistical and Reimbursement System Report Type Data Element Description 720 AVG PYMT RATE Rev Code 831 The average composite rate reimbursement by treatment Cond Code 74 type 720 AVG PYMT RATE Rev Code 831 The average composite rate reimbursement by treatment Cond Code 76 type 720 AVG PYMT RATE Rev Code 841 The average composite rate reimbursement by treatment Cond Code 73 type 720 AVG PYMT RATE Rev Code 841 The average composite rate reimbursement by treatment Cond Code 74 type 720 AVG PYMT RATE Rev Code 851 The average composite rate reimbursement by treatment Cond Code 73 type 720 AVG PYMT RATE Rev Code 851 The average composite rate reimbursement by treatment Cond Code 74 type 720 REV C
493. ree positions 058 are rolled up 329 LUPA 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 LUPA 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 LUPA 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 LUPA 0623 Displays by itself These fields are not populated on this report 329 LUPA All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 PEP 0023 Does not display These fields are not populated on this report 329 PEP 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 PEP 0274 Displays by itself These fields are not populated on this report 329 PEP 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 PEP 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 PEP 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 PEP 044X All revenue code lines
494. revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 119 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 119 TOTAL ACCOMODATIONS This category may include provider liable days that are non covered days This category may be used to prorate the Medicare Days field for cost reporting purposes 119 TOTAL ANCI LLARY All Medicare covered charges associated with revenue codes designated as ancillary 119 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as routine and ancillary 119 HOSPITAL SPECIFIC This line plus any federal specific amounts are the total DRG amounts other than outlier 119 FEDERAL SPECIFIC This line plus any hospital specific amounts are the total DRG amounts other than outlier 119 OUTLIER Summarizes cost outlier payments Value code 17 made under the Prospective Payment System 119 DSH LIP The DSH LIP amount value code 18 shown on the PS amp R report represents interim payments calculated by the PPS Pricer program For cost reporting purposes the DSH LIP amount must be recomputed for qualifying hospitals 119 IME TEACHING ADJ Indirect medical education Teaching adjustment Value Code 19 amount shown on the PS amp R are estimated payment
495. revenue codes designated as ancillary 81A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 81A DEDUCTIBLES The actual deductible amount from the paid claim record 81A COINSURANCE The actual coinsurance amount from the paid claim record 81A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 81A MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 81A OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports User Manual February 2009 Version No 2 0 Report Data B 91 Provider Statistical and Reimbursement System Report Type Data Element Description 81A NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 81A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions
496. rges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 85A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 85A GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 85A CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 85A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 85A COINSURANCE The actual coinsurance amount from the paid claim record 85A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance User Manual February 2009 Version No 2 0 Report Data B 44 Provider Statistical and Reimbursement System Report Type Data Element Description 85A NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 85A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 12P CLAI MS Currently this field has no cost report u
497. rges with outlier where the first three positions 027 excluding 0274 are rolled up 399 TOTAL 0274 Displays by itself Part B prosthetics and orthotics charges with outlier 399 TOTAL 029X All revenue codes lines Part B durable medical equipment charges with outlier where the first three positions 029 are rolled up 399 TOTAL 042X All revenue code lines Part B physical therapy count with outlier where the first three positions 042 are rolled up 399 TOTAL 043X All revenue code lines Part B occupational therapy count with outlier where the first three positions 043 are rolled up 399 TOTAL 044X All revenue code lines Part B speech count with outlier where the first three positions 044 are rolled up 399 TOTAL 055X All revenue code lines Part B nursing count with outlier where the first three positions 055 are rolled up 399 TOTAL 056X All revenue code lines Part B Med Soc Serv with outlier where the first three positions 056 are rolled up User Manual February 2009 Version No 2 0 Report Data B 152 Provider Statistical and Reimbursement System Report Type Data Element Description 399 TOTAL 057X All revenue code lines Part B home health aide count with outlier where the first three positions 057 are rolled up 399 TOTAL 058X All revenue code lines Part B other visits where the first three positi
498. ric character or is not in MM DD YYYY format User Manual February 2009 Version No 2 0 Error Messages C 33 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message E038 Service Period From All Fields must not be null Error E038 Service Dates in Selected Date s entry for Provider Service Periods ID contains a non Table numeric character or is not in MM DD YYYY format E038 Service Period From All Only numeric characters Error E038 Service Dates in Selected Date s entry for Provider Service Periods ID contains a non Table numeric character or is not in MM DD YYYY format E038 Service Period From All Entry must be in Error E038 Service Dates in Selected MM DD YYYY format Date s entry for Provider Service Periods ID 5 contains a non Table numeric character or is not in MM DD YYYY format E038 Service Period To All Field must not be null Error E038 Service Dates Date s entry for Provider ID 5 contains a non numeric character or is not in MM DD YYYY format E038 Service Period To All Only numeric characters Error E038 Service Dates Date s entry for Provider lt ID 5 contains a non numeric character or is not in MM DD YYYY format E038 Service Period To All Entry must be in Error E038 Service Dates MM DD YYYY format Date s entry for Provider lt ID 5 contains a non nume
499. ric character or is not in MM DD YYYY format E038 Service Period To All Field must not be null Error E038 Service Dates in Selected Date s entry for Provider Service Periods ID 5 contains a non Table numeric character or is not in MM DD YYYY format E038 Service Period To All Only numeric characters Error E038 Service Dates in Selected Service Periods Table Date s entry for Provider lt ID contains a non numeric character or is not in MM DD YYYY format User Manual February 2009 Version No 2 0 Error Messages C 34 Provider Statistical and Reimbursement System ID E038 Form Field Service Period To Dates in Selected Service Periods Table User Type All Validation Entry must be in MM DD YYYY format Error Message Error E038 Service Date s entry for Provider lt ID 5 contains a non numeric character or is not in MM DD YYYY format E042 Paid Date From Date All Only numeric characters Error E042 Paid Date s entry contains a non numeric character or is not in MM DD YYYY format E042 Paid Date From Date All Entry must be in MM DD YYYY format Error E042 Paid Date s entry contains a non numeric character or is not in MM DD YYYY format E042 Paid Date From Date All Field must not be null Error E042 Paid Date s entry contains a non numeric character or is not in MM
500. riority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 110 MSP PASS THRU RECONCILIATION This field is informational only and should not be included in the cost report This amount occurs in cases where Medicare has made no payment on the claim yet classifies it as PR Partial Recovery because of the estimated pass through payments The actual pass through amounts will be determined in the cost report The MSP Pass Thru Reconciliation amount must be ignored for cost reporting 110 OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 110 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc Ensure the amounts from report 118 are also transferred to the cost report 110 CALCULATED NET REIMB FOR PIP CLAIMS For intermediary use Indicates that provider received PIP payments May be used to identify duplicate payments 110 ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amoun
501. ription of each report template in addition to the reports generated based on each template Chapter 6 Consolidation Reports provides a description of the consolidation reports available in the PS amp R system Appendix A Report Details provides the following information for each report available in the PS amp R system report group report type report name service category provider type provider number range and an indicator specifying whether the report is included in the cost report Appendix B Report Data provides a list of the data elements that appear on inpatient or outpatient reports in the PS amp R system The appendix provides a description of each data element along with the type of data character numeric date etc Appendix C Error Messages lists the error messages used in the PS amp R system and provides corrective action for each error message Appendix D Glossary provides an explanation of terms used throughout the PS amp R system and this User Manual User Manual Introduction February 2009 Version No 2 0 1 2 Provider Statistical and Reimbursement System 2 System Overview and Common Features This chapter provides an overview of the PS amp R System e the startup procedure to follow when accessing the PS amp R System and a description of common features and menu options of the system If you do not already have access to the PS amp R System you must first register for Individuals Author
502. rmat Community Mental Health Center CMHC A facility that provides the following services e Outpatient services including specialized outpatient services for children the elderly individuals who are chronically ill and residents of the CMHC s mental health services area who have been discharge from inpatient treatment at a mental health facility e 24 hour a day emergency care services e Day treatment other than partial hospitalization services or psychosocial rehabilitation services e Screening for patients considered for admission to State mental health facilities to determine the appropriateness of such admission and e Consultation and education services User Manual February 2009 Version No 2 0 Glossary D 1 Provider Statistical and Reimbursement System Term Definition Comprehensive Inpatient Rehabilitation Facility CIRF A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities Services include physical therapy occupational therapy speech pathology social or psychological services and orthotics and prosthetics services Comprehensive Outpatient Rehabilitation Facility CORF A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities Services include physical therapy occupational therapy and speech
503. rmation 339 TOTAL CLAIM INTEREST PAYMENTS This is the Part A information 32M FULL EPISODES This is the Part B MSP LCC information 32M LUPA EPISODES This is the Part B MSP LCC information 32M PEP ONLY EPISODES This is the Part B MSP LCC information User Manual February 2009 Version No 2 0 Report Data B 136 Provider Statistical and Reimbursement System Report Type Data Element Description 32M SCIC ONLY EPISODES This is the Part B MSP LCC information 32M SCIC WITHIN A PEP This is the Part B MSP LCC information 32M TOTAL This is the Part B MSP LCC information 32M VISITS This is the Part B MSP LCC information 32M CHARGES This is the Part B MSP LCC information 32M REV CODE This is the Part B MSP LCC information 32M DESCRIPTION This is the Part B MSP LCC information 32M TOT SERVICES WITHOUT OUTLIER This is the Part B MSP LCC information 32M TOT SERVICES WITH OUTLIER This is the Part B MSP LCC information 32M TOT COVERED SERVICES This is the Part B MSP LCC information 32M EPISODES WITHOUT OUTLIER This is the Part B MSP LCC information 32M HIPPS REIMBURSEMENT WITHOUT This is the Part B MSP LCC information OUTLIER 32M EPISODES WITH OUTLIER This is the Part B MSP LCC information 32M HIPPS REIMBURSEMENT WITH This is the Part B MSP LCC information OUTLIER 32M OUTLIER REI MBURSEMENTS This is the Part B MSP LCC information
504. rmational only and should not be included in the cost report This amount occurs in cases where Medicare has made no payment on the claim yet classifies it as PR Partial Recovery because of the estimated pass through payments The actual pass through amounts will be determined in the cost report The MSP Pass Thru Reconciliation amount must be ignored for cost reporting 11T OTHER ADJ USTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 11T NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 11T CALCULATED NET REIMB FOR PIP CLAIMS For intermediary use Indicates that provider received PIP payments May be used to identify duplicate payments 11T ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 11A 18A 21A 118 and all other inpatient reports are transferred to the cost report 11T CLAIM INTEREST PAYMENTS Sum of interest paid on claims due to unti
505. rolled up 399 FULL 055X All revenue code lines Part B nursing count where the first three positions 055 are rolled up 399 FULL 056X All revenue code lines Part B Med Soc Serv where the first three positions 056 are rolled up User Manual February 2009 Version No 2 0 Report Data B 153 Provider Statistical and Reimbursement System Report Type Data Element Description 399 FULL 057X All revenue code lines Part B Home Health Aide count where the first three positions 057 are rolled up 399 FULL 058X All revenue code lines Part B other visits without outlier where the first three positions 058 are rolled up 399 FULL 059X All revenue code lines These fields are not normally used where the first three positions 059 are rolled up 399 FULL 060X All revenue code lines Part B Oxygen charges where the first three positions 060 are rolled up 399 FULL 062X All revenue code lines Part B Med Supplies charges where the first three positions 062 are rolled up 399 FULL 0623 Displays by itself Part B Surgical Dressings charges 399 FULL AII other Rev Codes display as All other they come in on the claim they do not roll up 399 LUPA 0023 Does not display These fields are not populated on this report 399 LUPA 027X All revenue code lines Part B Med Supplies charges where the first three positions 027 excludin
506. rsed 855 sssessessusss 5 34 5 8 xx0 All Other Report Template 2 2 anaasanansa naasa naan ehem 5 34 5 8 1 Inpatient Part B Cost Reimbursed 120 2 a 5 38 5 8 2 Outpatient Cost Reimbursed 130 eeeeaeeeseeeneeenes 5 38 5 8 3 Outpatient Other All Other Cost Reimbursed 140 5 38 5 8 4 SNF Inpatient Part B Cost Reimbursed 220 sese 5 38 5 8 5 SNF Outpatient Cost Reimbursed 230 ccccecceeeeeaeeeeeeeneeenes 5 38 5 8 6 Home Health Part B 340 22222 Hee nenne 5 38 5 8 7 Clinic Rural Health 710 2 2222222 HH 5 38 5 8 8 Federally Qualified Health Center 730 sss 5 38 User Manual February 2009 Version No 2 0 Table of Contents V Provider Statistical and Reimbursement System 5 8 9 Rehabilitation Facility 740 menm 5 38 5 8 10 Comprehensive Outpatient Rehabilitation Facilities 750 5 39 5 8 11 Community Mental Health Center 760 0 a 5 39 5 8 12 Critical Access Hospital 850 c sss mene 5 39 5 9 xxM xx9 Home Health Agency Report Template ssssssssssnn 5 39 5 9 1 Home Health PPS MSP LCC 32M cisseeseIHHH Hmm 5 43 5 9 2 Home Health PPS Part B Episodes 329 sess 5 44 5 9 3 Home Health Part A MSP LCC 33M issssss
507. rts that are generated based on the outpatient xxM xx9 Home Health Agency report template are Home Health PPS Part A MSP LCC 32M Home Health PPS Part B Episodes 329 Home Health Part A MSP LCC 33M Home Health PPS Part A Episodes 339 Home Health PPS Part A and Part B Episodes 399 A brief description of these reports is provided in the following sections 5 9 1 Home Health PPS MSP LCC 32M The Home Health PPS MSP LCC 32M report is a supplemental report to the Home Health PPS Part B Episodes 329 report The items reported on the Home Health PPS MSP LCC 32M report are included on the Medicare Cost Report User Manual Outpatient Reports February 2009 Version No 2 0 5 43 Provider Statistical and Reimbursement System 5 9 2 Home Health PPS Part B Episodes 329 The Home Health PPS Part B Episodes 329 report summarizes data included on Part B home health prospective payments episodes covered under a signed plan of treatment Part B home health data is broken out into different episodic units Services included on this report are typically not subject to deductibles or coinsurance The items reported on the Home Health PPS Part B Episodes 329 report are included on the Medicare Cost Report 5 9 3 Home Health Part A MSP LCC 33M The Home Health Part A MSP LCC 33M report is a supplemental report to the Home Health Part A Episodes 339 report The items reported on
508. rvice Period From Periods overlap and or Date this assures are not chronological for chronological service periods Provider ID 5 and that there is no overlapping service periods E092 Service Period To All Entry must be less than the Error E092 Service Dates in Selected next Service Period From Periods overlap and or Service Periods Date this assures are not chronological for Table chronological service periods Provider ID 5 and that there is no overlapping service periods User Manual February 2009 Version No 2 0 Error Messages C 38 Provider Statistical and Reimbursement System ID E094 Form Field Service Period From Dates in Selected Service Periods Table User Type All Validation Entry is one day greater than previous Service Period To Date this checks to see if the service periods are consecutive Error Message If the Include Extract File was selected Warning You have selected non consecutive service periods for Provider ID 5 This will exclude cost report data on the extract file Do you wish to continue Clicking the Continue button will bring user to next request page clicking the Back button will bring user back to the dates page and allow them to make any changes OR If the Include Extract File was not selected Warning You have selected non consecutive service periods for Provider ID 5 Do
509. ry 180 RVL This field reflects the units paid per RUG category User Manual February 2009 Version No 2 0 Report Data B 34 Provider Statistical and Reimbursement System Report Type Data Element Description 180 RHC This field reflects the units paid per RUG category 180 RHB This field reflects the units paid per RUG category 180 RHA This field reflects the units paid per RUG category 180 RHX This field reflects the units paid per RUG category 180 RHL This field reflects the units paid per RUG category 180 RMC This field reflects the units paid per RUG category 180 RMB This field reflects the units paid per RUG category 180 RMA This field reflects the units paid per RUG category 180 RMX This field reflects the units paid per RUG category 180 RML This field reflects the units paid per RUG category 180 RLB This field reflects the units paid per RUG category 180 RLA This field reflects the units paid per RUG category 180 RLX This field reflects the units paid per RUG category 180 SE3 This field reflects the units paid per RUG category 180 SE2 This field reflects the units paid per RUG category 180 SE1 This field reflects the units paid per RUG category 180 SSC This field reflects the units paid per RUG category 180 SSB This field reflects the units paid per RUG category 180 SSA This field reflect
510. ry 345 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 345 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 345 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 345 COINSURANCE The actual coinsurance amount from the paid claim record 345 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 345 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 345 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 745 CLAIMS Currently this field has no cost report usage 745 UNITS The number of units applicable to each revenue code 745 CHARGES The charges applicable to each revenue code 745 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 745 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listin
511. s Part B medical supplies charges with outlier where the first three positions 062 are rolled up 399 SCIC PEP 0623 Displays by itself Part B surgical dressings charges with outlier 399 SCIC PEP All other Rev Codes display All other Part B revenue code charges as they come in on the claim they do not roll up 399 SCIC 0023 Does not display These fields are not populated on this report 399 SCIC 027X All revenue code lines Part B medical supplies charges with outlier where the first three positions 027 excluding 0274 are rolled up 399 SCIC 0274 Displays by itself Part B prosthetics and orthotics charges with outlier 399 SCIC 029X All revenue codes lines Part B durable medical equipment charges with outlier where the first three positions 029 are rolled up 399 SCIC 042X All revenue code lines Total physical therapy covered charges during SCIC only where the first three positions 042 episode are rolled up 399 SCIC 043X All revenue code lines Total occupational therapy covered charges during SCIC only where the first three positions 043 episode are rolled up 399 SCIC 044X All revenue code lines Total speech therapy covered charges during SCIC only where the first three positions 044 episode are rolled up 399 SCIC 055X All revenue code lines Total covered charges related to nursing services during SCIC where the first three positions 055 only episode are rolled up 399 SCIC
512. s where the first three positions 058 are rolled up 399 PEP 059X All revenue code lines Total visit covered charges for various disciplines for PEP where the first three positions 059 episode are rolled up 399 PEP 060X All revenue code lines Part B oxygen charges with outlier where the first three positions 060 are rolled up 399 PEP 062X All revenue code lines Part B medical supplies charges with outlier where the first three positions 062 are rolled up 399 PEP 0623 Displays by itself Part B surgical dressings charges with outlier 399 PEP All other Rev Codes display as All other Part B revenue code charges they come in on the claim they do not roll up 399 SCIC PEP 0023 Does not display These fields are not populated on this report 399 SCIC PEP 027X All revenue code lines Part B medical supplies charges with outlier where the first three positions 027 excluding 0274 are rolled up 399 SCIC PEP 0274 Displays by itself Part B prosthetics and orthotics charges with outlier 399 SCIC PEP 029X All revenue codes Part B durable medical equipment charges with outlier lines where the first three positions 029 are rolled up 399 SCIC PEP 042X All revenue code lines Total physical therapy covered charges during SCIC PEP where the first three positions 042 episode are rolled up 399 SCIC PEP 043X All revenue code lines Total occupational therapy covered charges during SCI C PEP where
513. s are first allocated to the extent of any deductibles or coinsurance 12A NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 12A CLAIM INTEREST PAYMENTS Sum of interest paid on claims due to untimely claims processing Currently this field has no cost report usage 13A CLAI MS Currently this field has no cost report usage 13A UNITS The number of units applicable to each revenue code 13A CHARGES The charges applicable to each revenue code User Manual February 2009 Version No 2 0 Report Data B 36 Provider Statistical and Reimbursement System Report Type Data Element Description 13A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 13A DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 13A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 13A GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 13A CASH DEDUCTIBLE The actual cash deductible amoun
514. s etc 115 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions User Manual February 2009 Version No 2 0 Report Data B 33 Provider Statistical and Reimbursement System Report Type Data Element Description 210 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 210 CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 210 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 210 COINSURANCE The actual coinsurance amount from the paid claim record 210 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 210 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 210 CALCULATED NET REIMB FOR PIP For intermediary use Indicates that provider received PIP CLAIMS payments May be used to identify duplicate payments 210 ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP
515. s have been selected click Continue The following page appears Provider Statistical amp Reimbursement System 4 LA Home Report Inbox Request Report Favorite Requests Request Summary Request Detail Detail Report Request 2 Select Report s C By Service Type All F Include 998 Report M Exclude PHI on Report s C By Report Group Search B 1 a H IF Include 998 Report M Exclude PHI on Report s C By Report Type Search SED GED CARE c CC ST REIMBURSED F Exclude PHI on Report s Back Continue 4 Selectthe report s to generate for the selected provider s The following table contains a description of each field on the page Definition Required if neither By Report Group nor By Report Type is selected Select the By Service Type option and then select the service type to include in the report Field By Service Type Performing Tasks in the PS amp R User Manual February 2009 Version No 2 0 3 16 Provider Statistical and Reimbursement System Field Definition Include 998 Report Optional Select the check box to include the Consolidation of Outpatient Claims Excluding MSP LCC 998 report in this request Exclude PHI on Reports Optional Select the check box to exclude all personal health information on the reports generated in this request By Report Group Required if neither By Service Type nor By Report Type is se
516. s made on a bill by bill basis by the PPS Pricer program For cost reporting purposes the amount must be recomputed 119 NEW TECHNOLOGY Summarizes new technology payments Value code 77 made under the Prospective Payment System 119 IPF ECT Summarizes IPF ECT Inpatient Psych Facility Electro Convulsive Therapy payments made under the Prospective Payment System User Manual February 2009 Version No 2 0 Report Data B 8 Provider Statistical and Reimbursement System Report Type Data Element Description 119 TOTAL OPERATI NG PAYMENTS This is the sum of the operating amounts for HSP FSP outlier DSH LIP IME teaching adjustment new technology IPF ECT and exception payments 119 HOSPITAL SPECIFIC This is the hospital specific portion of the PPS payment for capital The field will be zero for providers paid based on the hold harmless old capital or the hold harmless 100 percent federal method and for new hospitals during their first two years of operation 119 FEDERAL SPECIFIC This field includes the federal portion of the PPS payment for capital This field will also include the new capital amount for hospitals paid under the hold harmless old capital method 119 OUTLIER This field will show the outlier portion of the PPS payment for capital 119 HOLD HARMLESS This field shows the hold harmless amount paid for old capital based on the hold harmless o
517. s Raimb 000 LESS Cash Deduct 000 Blood Deduct 000 Coins yano ms 200 Paye Rad Net Raimb 200 Reimbursements Gross Reimb 000 LESS Cash Deduct 000 Blood Daduct 000 Coins 000 MP 000 Pay Rad Net Raimb 000 Page 5 Report OD42202 Report Type 130 Paid Dates 01 01 00 to 10 01 06 Additional Information MSP Cash Deduct 260 MSP Blood Deduct 0 00 MSP Coins 000 Caim interest 0 00 Caim Report Splits 130 135 13P MSP Cash Deduct 000 MSP Blood Deduct 000 MSP Coins 000 Claim interest 000 Caim Report Splits 130 135 13P Additional Information MSP Cash Deduct 000 MSP Blood Deduct 0 00 MSP Coins 000 Claim interest 000 12 33 54 PM User Manual February 2009 Version No 2 0 Outpatient Reports 5 36 Provider Statistical and Reimbursement System Exhibit 5 19 Outpatient xxO All Other Payment Reconciliation Report Template Last Page PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Service Month End N A OUTPATIENT COST REIMBURSED Report Run Date 02 07 07 Provider FYE 09 30 Provider Number T00044 SACRED SISTERS MEDICAL CENTER Service Period and Report Type Totals Service Period 01 01 2000 01 01 2006 Gross Cash Blood Line item Units COUPS i Dedut Dedut 775 E RAD i TOTA E 0 20 0 00 5 00 000 0 00 2 00 0 00 Report Type 130 Totals for SACRED SISTERS MEDICAL C
518. s health insurance coverage and health care services for a fixed pre paid premium and modest additional co payments and deductibles RISK HMOs have contracts with Medicare on a prospective capitation payment basis for providing health care to Medicare beneficiaries HCRIS Healthcare Provider Cost Reporting Information System Home Health Agency HHA A public or private organization that provides home care services such as skilled nursing care physical therapy occupational therapy speech therapy and personal care by home health aides Home Health Care Health care services provided in the home on a part time basis for the treatment of an illness or injury Medicare pays for home care only if the type of care needed is skilled and required on an intermittent basis and is intended to help people recover or improve from an illness not to provide unskilled services over a long period of time Hospice A publicly or privately operated program primarily engaged in providing pain relief symptom management and supportive services to terminally ill people and their families Individuals Authorized Access to CMS Computer Services LACS IACS is an on line application used to register and provision authorized users for access to CMS Part C and D business applications and systems Inactive A provider that is inactive for a Fiscal Intermediary Fiscal Intermediaries service many providers When a provide
519. s the units paid per RUG category 180 CC2 This field reflects the units paid per RUG category 180 CC1 This field reflects the units paid per RUG category 180 CB2 This field reflects the units paid per RUG category 180 CB1 This field reflects the units paid per RUG category 180 CA2 This field reflects the units paid per RUG category 180 CA1 This field reflects the units paid per RUG category 180 IB2 This field reflects the units paid per RUG category 180 IB1 This field reflects the units paid per RUG category 180 IA2 This field reflects the units paid per RUG category 180 IA1 This field reflects the units paid per RUG category 180 BB2 This field reflects the units paid per RUG category 180 BB1 This field reflects the units paid per RUG category 180 BA2 This field reflects the units paid per RUG category 180 BA1 This field reflects the units paid per RUG category 180 PE2 This field reflects the units paid per RUG category 180 PE1 This field reflects the units paid per RUG category 180 PD2 This field reflects the units paid per RUG category User Manual February 2009 Version No 2 0 Report Data B 35 Provider Statistical and Reimbursement System Report Type Data Element Description 180 PD1 This field reflects the units paid per RUG category 180 PC2 This field reflects the units paid per RUG category 180 PCI This field reflects t
520. sage 12P UNITS The number of units applicable to each revenue code 12P CHARGES The charges applicable to each revenue code 12P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 12P DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 12P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 12P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 12P OUTLIER The outlier portion of the OPPS payment for the APC 12P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 12P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 12P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 12P COINSURANCE The actual coinsurance amount from the paid claim record 12P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 12P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medic
521. scharge exception interim payment for capital related costs that qualifying hospitals are entitled to receive in accordance with Medicare payment policy 118 TOTAL CAPITAL PAYMENTS This is the sum of the capital amounts for HSP FSP outlier hold harmless disproportionate share adjustment indirect medical education and exception payments 118 GROSS REIMBURSEMENT This amount is the sum of total operating and total capital payments 118 DEVICE CREDIT This amount represents the credit that a provider received to replace a medical device that may have been defective or under warranty This amount can be identified with a value code of FD on the claim 118 CASH DEDUCTIBLE The sum of actual cash deductible amount from the paid claim records 118 BLOOD DEDUCTIBLE The sum of actual blood deductible amount from the paid claim records 118 COINSURANCE The sum of actual coinsurance amount from the paid claim records 118 NET MSP PAYMENTS The sum of net payments made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 118 MSP PASS THRU RECONCILIATI ON This field is informational only and should not be included in the cost report This amount occurs in cases where Medicare has made no payment on the claim yet classifies it as PR Partial Recovery because of
522. section shows the number of claims for each reporting period This section also shows Total Ambulance Trips and Total Ambulance Miles which are unique to the xxZ report The charge section displays the number of units and the total dollar amount of the revenue code being reported The reimbursement section displays how Net Reimbursement is calculated Finally the additional information section displays the claim interest payments and the Total Gross Fee Schedule Amount The xxZ Outpatient Ambulance Blend Payment Reconciliation detail report template is divided into Claim Information Reimbursements and Additional Information sections The claim information section displays patient information such as the patient name DCN Line Item Reimbursement Total Ambulance Trips Total Ambulance Miles and the charges for the revenue codes The reimbursements section shows how Net Reimbursement is calculated The additional information section shows the deductible amounts claim interest and Total Gross Fee Schedule The template also provides a monthly totals section that sums the information from the sections above An example of the xxZ Outpatient Ambulance Blend Provider Summary report template and the xxZ Outpatient Ambulance Blend Payment Reconciliation detail report template follow User Manual Outpatient Reports February 2009 Version No 2 0 5 22 Provider Statistical and Reimbursement System Exhibit 5 10 Outpatient xxZ Ambulance
523. sion No 2 0 Error Messages C 20 Provider Statistical and Reimbursement System Form Field User Type Validation Error Message ID Select Load Date CMS Month Day and Year values Error E001 Load Date s E001 To FI MAC must be valid entry contains an invalid Admin month day and or year Select Load Date CMS Entry must be greater than or Error E312 Load Dates do E312 To FI MAC equal to corresponding Load not have a valid date range Admin Date From date From from date To to dates Submit CMS If the report request yields no Error E No report can be FI MAC results generated for the parameters Admin selected C 14 Detail Report Request Load Control The Detail Report Request Load Control page error messages are presented in the following table Exhibit C 14 Detail Report Request Load Control Page Error Messages Form Field User Type Validation Error Message ID Load Control CMS You must select either PDF or Error E046 No report format E046 Miscellaneous FI MAC CSV as the report format to was selected Please choose a Report Request Admin continue report format before Select Format continuing Page Load Control CMS The Your Request Name Error E047 Your Request E047 Confirmation Page FI MAC field cannot be null Name is not entered Please after selecting a Admin enter a request name to format type from proceed the miscellan
524. sion No 2 0 Report Data B 70 Provider Statistical and Reimbursement System Report Type Data Element Description 742 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 742 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 742 COINSURANCE The actual coinsurance amount from the paid claim record 742 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 742 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 742 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 752 CLAI MS Currently this field has no cost report usage 752 UNITS The number of units applicable to each revenue code 752 CHARGES The charges applicable to each revenue code 752 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 752 DESCRIPTION The description of each revenue code and its associated
525. sitions 062 excluding 0623 are rolled up 0623 Displays by itself All other Rev Codes display as they come in on the claim they do not roll up 399 TOTAL UNDUPLICATED CENSUS COUNT 399 FULL EPISODES Total Part A and Part B undup census count for 60 day full episodes 399 LUPA EPISODES Total Part A and Part B undup census count for 4 or fewer visits during 60 day episode period User Manual February 2009 Version No 2 0 Report Data B 140 Provider Statistical and Reimbursement System Report Type Data Element Description 399 PEP ONLY EPISODES Total Part A and Part B undup census count for transfer or discharge and return within 60 days 399 SCIC ONLY EPISODES Total Part A and Part B undup census count for significant chg in condition revised diagnosis 399 SCIC WITHIN A PEP Total Part A and Part B undup census count for SCIC within PEP definition 399 TOTAL Total Part A and Part B undup census counts for all episode types 399 VISITS Total Part A and Part B visits 399 CHARGES Total Part A and Part B covered charges 399 REV CODE 399 DESCRIPTION 399 TOT SERVICES WITHOUT OUTLIER 399 TOT SERVICES WITH OUTLIER 399 TOT COVERED SERVICES 399 Rev Code PDF Revenue Code CSV Column 399 SERVICES WITHOUT OUTLIER 399 FULL 0023 Does not display 399 FULL 027X All revenue code lines This is the total Part A and Part B
526. spital Based or Independent Renal Dialysis Center Composite Rate Services 720 on ciere ARE ER E E E e RV eut 5 10 5 2 3 Hospital Based or Independent Renal Dialysis Center Fee Reimb rseqg E25 oci nescence Banana c e t do waa SS AU a Y AG danke 5 10 5 3 xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Report Template 2 0 mmm memes nnns 5 10 5 3 1 Inpatient Part B MSP LCC 124 csse mene 5 14 5 3 2 Outpatient All Other MSP LCC 134A a 5 14 5 3 3 Outpatient Other MSP LCC 14A cesses men 5 14 5 3 4 SNF Inpatient Part B MSP LCC 224 ccs 5 14 5 3 5 SNF Outpatient MSP LCC 23A a 5 14 5 3 6 Home Health Part B MSP LCC 34A ccssssesse mm 5 14 5 3 7 Clinic Rural Health MSP LCC 71A a 5 14 5 3 8 Federally Qualified Health Center MSP LCC 734A eese 5 14 5 3 9 Rehabilitation Facility MSP LCC 74A sssssess HI 5 15 5 3 10 Comprehensive Outpatient Rehabilitation Facilities MSP LCC 75A 5 15 5 3 11 Community Mental Health Center MSP LCC 764 sees 5 15 5 3 12 ASC and ASC Fee Schedule MSP LCC 834A 0 a 5 15 5 3 13 Critical Access Hospital MSP LCC 85A 00 5 15 User Manual February 2009 Version No 2 0 Table of Contents Provider Statistical and Reimbursement System 5 4 xxP Outpatient Prospective Payme
527. ss m 5 44 5 9 4 Home Health PPS Part A Episodes 339 sss 5 44 5 9 5 Home Health PPS Part A and Part B Episodes 399 5 44 5 10 322 332 Home Health Agency Report Template ssssn 5 44 5 10 1 Home Health PPS Part B RAP 322 Henn 5 46 5 10 2 Home Health PPS Part A RAP 332 Henn 5 46 5 11 81x 82x Hospice Report Template uasananaasanaasanansanannassanananaasansnsanana 5 47 5 11 1 Hospice Non Hospital Based MSP LCC 814 eccerre 5 49 5 11 2 Hospice Non Hospital Based 810 cccceecceee cece sees cues eeneeeneeenes 5 50 5 11 3 Hospice Hospital Based MSP LCC 82A 0020 saaan 5 50 5 11 4 Hospice Hospital Based 820 2 0200002 aaaaaaaa aaa 5 50 5 12 831 ASC and ASC Fee Schedule After 12 90 sess 5 50 6 Consolidation Reports eeecesieseeseesess AA AA 6 1 6 1 998 Consolidation of Outpatient Claims Excluding MSP LCC sesssss 6 1 6 2 1000 Consolidated Summary of All Report Types sssss m 6 2 Report Details A 1 Report Data AA B 1 Error ILLII nM C 1 C l HOME Page ADD ai dad cahavanad seuau Gefen dua C 1 C 2 Summary Report Request Select Provider s 20 10 0 C 2 C 3
528. st Payments for PEP 329 SCIC PEP EPISODES WITHOUT This is Part B number of episodes without outlier for PEP OUTLIER 329 SCIC PEP HIPPS REIMBURSEMENT This is Part B HHPPS reimbursement without outlier for WITHOUT OUTLIER SCIS PEP 329 SCIC PEP EPISODES WITH OUTLIER This is Part B number of episodes with outlier for SCIC PEP 329 SCIC PEP HIPPS REIMBURSEMENT This is Part B HHPPS reimbursement with outlier for SCIC PEP WITH OUTLIER 329 SCIC PEP OUTLIER REI MBURSEMENTS This is Part B OUTLIER reimbursement for SCI C PEP 329 SCIC PEP PROSTHETI C ORTHOTI C This is Part B P amp O for SCIC PEP DEVICES 329 SCIC PEP DME This is Part B DME for SCIS PEP 329 SCIC PEP OXYGEN This is Part B oxygen for SCIC PEP 329 SCIC PEP OTHER FEE This is Part B other fee SCIC PEP REI MBURSEMENTS 329 SCIC PEP GROSS REI MBURSEMENT Part B Gross Reimbursement for SCI C PEP 329 SCIC PEP DEDUCTIBLES This is Part B deduct for SCIC PEP 329 SCIC PEP COINSURANCE This is Part B coinsurance for SCIC PEP 329 SCIC PEP NET MSP PAYMENTS This is Part B MSP recon for SCIC PEP 329 SCIC PEP MSP RECONCILIATI ON This is Part B net MSP payment for SCIC PEP 329 SCIC PEP OTHER ADJUSTMENTS This is Part B other adjustment for SCIC PEP 329 SCIC PEP NET REIMBURSEMENT This is Part B NET reimbursement for SCIC PEP 329 SCIC PEP CLAIM INTEREST PAYMENTS Part B Claim Interest Payments for SCIC PEP 329 SCIC EPISODES WITHOUT OUTLIER Part B number of episodes without outlier fo
529. st three positions 029 are rolled up 329 PEP 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 PEP 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 PEP 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 PEP 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 108 Provider Statistical and Reimbursement System Report Type Data Element Description 329 PEP 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 PEP 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 PEP 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 PEP 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 PEP 060X All revenue code lines These fields are not
530. surance 225 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 225 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 235 CLAIMS Currently this field has no cost report usage 235 UNITS The number of units applicable to each revenue code 235 CHARGES The charges applicable to each revenue code 235 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 235 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 235 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 235 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 235 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 235 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 235 COINSURANCE The actual coinsurance amount from the paid claim record 235 NET MSP PAYMENTS The net payment made by a highe
531. t xxZ Ambulance Blend Payment Reconciliation Detail Report Template aaa outta cedet Ma aude or iru er all DLL tr eod 5 24 Outpatient xx2 Vaccines Provider Summary Report Template 5 26 Outpatient xx2 Vaccines Payment Reconciliation Detail Report Templates desit ed dede edant wea d Rd 5 27 Outpatient xx5 Fee Reimbursed Provider Summary Report Template 5 30 Outpatient xx5 Fee Reimbursed Payment Reconciliation Detail Report Template First Page User Manual February 2009 Version No 2 0 Table of Contents ix Exhibit 5 16 Exhibit 5 17 Exhibit 5 18 Exhibit 5 19 Exhibit 5 20 Exhibit 5 21 Exhibit 5 22 Exhibit 5 23 Exhibit 5 24 Exhibit 5 25 Exhibit 5 26 Exhibit 5 27 Exhibit 5 28 Exhibit 5 29 Exhibit 5 30 Exhibit 5 31 Exhibit 6 1 Exhibit 6 2 Exhibit A 1 Exhibit B 1 Exhibit C 1 Provider Statistical and Reimbursement System Outpatient xx5 Fee Reimbursed Payment Reconciliation Detail Report Template Last Page 220121 eene e eme em esses 5 32 Outpatient xxO All Other Provider Summary Report Template 5 35 Outpatient xxO All Other Payment Reconciliation Report Template First Page ANY 5 36 Outpatient xxO All Other Payment Reconciliation Report Template Last Page 4 ueri NASAAN ATA ree a Tree eva x Vedat nang PU e ap EE 5 37 Outpatient xxM xx9 Medicare Secondary Payer Lower Cost or Charge MSP LCC and Episodes Su
532. t and press Spacebar to make your selections Shift F8 again when finished Top of page Ctrl Home Bottom of page Ctrl End Scroll page down Page Down Scroll page up Page Up Visual browsers highlight the current link with a focus In Internet Explorer it appears as a dotted border around the link It is the link with the focus that will be acted upon when the user presses Enter User Manual System Overview and Common Features February 2009 Version No 1 2 15 Provider Statistical and Reimbursement System 3 Performing Tasks in the PS amp R If you log in using an FI MAC user ID and password the following page appears Cs Provider Statistical amp Reimbursement System Site Papal Announce mena FI MAC 14000 Thursday Augu ome Home Report Inbox Request Report User Preferences PS amp R Home Welcome to The Redesigned Provider Statistical and Reimbursement System User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 1 Provider Statistical and Reimbursement System Note The first time you log in to the Provider Statistical and Reimbursement System if you have multiple contractor IDs assigned you are prompted to select the contractor ID for which to generate report requests and view report output Click the radio button corresponding to the contractor with which to work Click the Save Preference check box to set the contractor as the default cont
533. t Reconciliation Detail Report Template First Page ceste nies eisai ys weed NG PARA 4 18 Inpatient 18x and 21x Payment Reconciliation Detail Report Template Last Page rented leo dt deme ed deer ata dese um reae Wa 4 19 Outpatient 72x Provider Summary Report Template 5 8 Outpatient 72x Payment Reconciliation Detail Report Template 5 9 Outpatient xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Provider Summary Report Template 2 s asana eee eee teeta nananakaw 5 11 Outpatient xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Payment Reconciliation Detail Report Template First Page 5 12 Outpatient xxA Medicare Secondary Payer Lower Cost or Charge MSP LCC Payment Reconciliation Detail Report Template Last Page Outpatient xxP Outpatient Prospective Payment System OPPS Provider Summary Report Template First Page 0 2 m 5 16 Outpatient xxP Outpatient Prospective Payment System OPPS Provider Summary Report Template Last Page Outpatient xxP Outpatient Prospective Payment System OPPS Payment Reconciliation Detail Report Template First Page sssessessss 5 18 Outpatient xxP Outpatient Prospective Payment System OPPS Payment Reconciliation Detail Report Template Last Page Outpatient xxZ Ambulance Blend Provider Summary Report Template 5 23 Outpatien
534. t Report 5 7 10 Community Mental Health Center Fee Reimbursed 765 The Community Mental Health Center Fee Reimbursed 765 report shows covered charges and reimbursement by revenue code for fee reimbursed services The items reported on the Community Mental Health Center Fee Reimbursed 765 report are included on the Medicare Cost Report 5 7 11 ASC and ASC Fee Schedule Fee Reimbursed 835 The ASC and ASC Fee Schedule Fee Reimbursed 835 report shows covered charges and reimbursements by revenue code for fee reimbursed services The items reported on the ASC and ASC Fee Schedule Fee Reimbursed 835 report are included on the Medicare Cost Report 5 7 12 Critical Access Hospital Fee Reimbursed 855 The Critical Access Hospital Fee Reimbursed 855 report shows covered charges and reimbursements by revenue code for fee reimbursed services The items reported on the Critical Access Hospital Fee Reimbursed 855 report are included on the Medicare Cost Report 5 8 xx0 All Other Report Template The Outpatient xx0 All Other Provider Summary report template displays summary statistic charge reimbursement and additional information sections for one reporting period up to a maximum of four reporting periods Note that the report always contains column headings for each of the four possible reporting periods even if the report contains fewer than four reporting periods The data displayed in each section is determined
535. t Reports provides a description of the Outpatient reports available in the PS amp R System See Appendix F Report Details for a definition of the data elements available on reports User Manual February 2009 Version No 2 0 4 2 Inpatient Reports Provider Statistical and Reimbursement System 4 1 Inpatient Report Type Assignment Claims data submitted to the PS amp R System in the Paid Claims file are processed for assignment to inpatient report groups according to the following sequence e 11x e 18x e 21x e 410 A provider s Paid Claims file is processed for inpatient report depending on the claim s bill type and routes the claim through the appropriate report type assignment logic All claims that do not satisfy requirements for inpatient reports are automatically processed for outpatient reports and home health agency reports Once a claim satisfies the requirements for presentation on a report the claim is not processed further For example if a claim s bill category is 21x the claim is routed through the 21x report type assignment logic If a claim satisfies requirements for the Inpatient Fee Reimbursed 115 report the claim is written to this report If a claim does not satisfy the Inpatient Fee Reimbursed 115 report requirements the claim continues through the subsequent report processing sequence until it matches a report s requirements The following sections document the processing requirements for a cla
536. t Spit 110720725 hidi 42394 vs sao Sandee Prost aue Paye Racks Sarita Thee emet i rc IF ee at Ne MORE G Bi Fras 1 Cou tenb 39450 MSP Cah Deduct sooo oem 2040479314008 Trans Type MS Mso Deduct p m Cont ee 039920000090 Precemar iC oao ben MS Cont pra Med Rerd e 121082000030 2 LT 1 Cath Deduet 500 Caim lotarest 3002 perd nm tota t sses gs0 SEM SOM yo s sae Seed deter 800 Calm Raport Spise 1072072 raid or QUA sim Sarita Prom QUUM Sarita Thee sim furi Ne MKMS Shen 1 5450 MSP Cah Deut sao oen Dowson Type MS Misod Deduct 005 mane 03009000000 Procamor i0 006 MS Cont soo Mag Reed 04025000000 lorn lassol Y nago 200 000 dim no MC Ne 495153069 Sised Deduct 200 Caim Report Spline 1020725 Repi Or 042194 TOTAL 1 5450 sso som SOO SISI 000 san sao 010104 aswa faso sesso 000 000 327 200 Nat Ramb iim Jan 30 2007 zii nag Disclaimer The content of this report is confidential and may be privileged or otherwise protected from disclosure and is solely for the use of the person s or entity for whom it is intended User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 32 Provider Statistical and Reimbursement System 4 Inpatient Reports The PS amp R System consists of a number of inpatient reports that are based on report templates that define a consistent layout for multiple reports The reports are presented in the order in wh
537. t display These fields are not populated on this report 339 TOTAL 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 TOTAL 0274 Displays by itself These fields are not populated on this report 339 TOTAL 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 120 Provider Statistical and Reimbursement System Report Type Data Element Description 339 TOTAL 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 TOTAL 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 339 TOTAL 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 339 TOTAL 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up 339 TOTAL 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 339 TOTAL 057X All revenue code lines These fields are not populated on this
538. t from the paid claim record 13A BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 13A COINSURANCE The actual coinsurance amount from the paid claim record 13A NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 13A NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 13A CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 14A CLAI MS Currently this field has no cost report usage 14A UNITS The number of units applicable to each revenue code 14A CHARGES The charges applicable to each revenue code 14A REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 14A DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 14A TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancil
539. t populated on this report they come in on the claim they do not roll up 329 SCIC PEP 0023 Does not display These fields are not populated on this report 329 SCIC PEP 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 SCIC PEP 0274 Displays by itself These fields are not populated on this report 329 SCIC PEP 029X All revenue codes These fields are not populated on this report lines where the first three positions 029 are rolled up 329 SCIC PEP 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 SCIC PEP 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are rolled up 329 SCIC PEP 044X All revenue code lines These fields are not populated on this report where the first three positions 044 are rolled up 329 SCIC PEP 055X All revenue code lines These fields are not populated on this report where the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 97 Provider Statistical and Reimbursement System Report Type Data Element Description 329 SCIC PEP 056X All revenue code lines These fields are not populated on this report
540. t report The MSP Pass Thru Reconciliation amount must be ignored for cost reporting User Manual February 2009 Version No 2 0 Report Data B 16 Provider Statistical and Reimbursement System Report Type Data Element Description 11R OTHER ADJ USTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 11R NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 11R CALCULATED NET REIMB FOR PIP CLAIMS For intermediary use Indicates that provider received PIP payments May be used to identify duplicate payments 11R ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 11A 18A 21A 118 and all other inpatient reports are transferred to the cost report 11R CLAIM INTEREST PAYMENTS Sum of interest paid on claims due to untimely claims processing Currently this field has no cost report usage 11R IRF PENALTY AMOUNT The 2596
541. t to coinsurance and deductible The items reported on the Home Health Part B MSP LCC 34A report are not to be included on the Medicare Cost Report 5 3 7 Clinic Rural Health MSP LCC 71A The Clinic Rural Health MSP LCC 71A report is a supplemental report to the Clinic Rural Health 710 report The items reported on the Clinic Rural Health MSP LCC 71A report are not to be included on the Medicare Cost Report 5 3 8 Federally Qualified Health Center MSP LCC 73A The Federally Qualified Health Center MSP LCC 73A report is a supplemental report to the Federally Qualified Health Center 730 report The items reported on the Federally Qualified Health Center MSP LCC 73A report are not to be included on the Medicare Cost Report User Manual Outpatient Reports February 2009 Version No 2 0 5 14 Provider Statistical and Reimbursement System 5 3 9 Rehabilitation Facility MSP LCC 74A The Rehabilitation Facility MSP LCC 74A report is a supplemental report to the Rehabilitation Facility 740 report The items reported on the Rehabilitation Facility MSP LCC 74A report are not to be included on the Medicare Cost Report 5 3 10 Comprehensive Outpatient Rehabilitation Facilities MSP LCC 75A The Comprehensive Outpatient Rehabilitation Facilities MSP LCC 75A report is a supplemental report to the Comprehensive Outpatient Rehabilitation Facilities 750 report The items reported on the Compre
542. tal speech therapy covered charges during PEP episode where the first three positions 044 are rolled up 399 PEP 055X All revenue code lines Total covered charges related to nursing services during PEP where the first three positions 055 episode are rolled up 399 PEP 056X All revenue code lines Total covered charges related to med soc serv during PEP where the first three positions 056 are rolled up episode User Manual February 2009 Version No 2 0 Report Data B 155 Provider Statistical and Reimbursement System Report Type Data Element Description 399 PEP 057X All revenue code lines Total covered charges related to home health aide serv during where the first three positions 057 PEP episode are rolled up 399 PEP 058X All revenue code lines Part B other visits without outlier where the first three positions 058 are rolled up 399 PEP 059X All revenue code lines Total visit covered charges for various disciplines for PEP where the first three positions 059 episode are rolled up 399 PEP 060X All revenue code lines Part B oxygen charges where the first three positions 060 are rolled up 399 PEP 062X All revenue code lines Part B medical supplies charges where the first three positions 062 are rolled up 399 PEP 0623 Displays by itself Part B surgical dressings charges 399 PEP All other Rev Codes
543. tem Code PES Code UN Charee Roimb Deduct Deduct CPE MSP Red Raimb 14900 0300 60001 1 4500 300 200 2 09 0 00 0 00 5300 0301 20048 20048 1 530584 1183 000 0 09 0 00 0 00 1183 0301 82565 ATPO2 1 1590 411 000 200 0 00 0 99 411 0301 24520 ATPO2 1 1550 317 000 000 000 0 00 317 0305 85049 1 2100 625 2000 0009 000 0 00 525 0305 85610 1 32070 549 000 500 000 0 00 5 49 TOTAL LI 4534 3345 000 000 0 09 000 3385 1 Rey Panel Gross Cash Blood Psy Line item Code PCS Cada UNG ABS Raimb Deduct Deduct MSP Red Raimb 14000 0305 85025 1 45 15 51026 00 00 000 0 00 1086 TOTAL 1 s4515 1085 000 SOLO 0 00 000 1086 Gross Cash Sood Lina Item Unis chames a Deue Daug Cons MSP Pay Rad a samoa 447 000 000 000 200 saan TOTAL Reimbursements Additional Information Gross Reimb 33 85 MSP Cash Deduct 0 00 Less MSP Sicod Deduct 000 MSP Coins 0 00 Cash Deduct 000 Claim interest 000 Blood Deduct 2 00 Claim Report Splits 130 135 13P Coins 200 MSP 2 00 Psyc Red Nati pr Gross Reimb 310 86 MSP Cash Deduct 000 Leeg MSP Bicod Deduct 000 MSP Coins 000 Cash Deduct 0 00 Claim interest 200 Blood Deduct 5 00 Claim Report Splits 130 135 13P Coins 000 MSP 000 Psyc Red Nat Reimb 1085 Reimbursements Additional Information Gross Reimb 4471 MSP Cash Deduct 000 Less MSP Sicod Deduct 000 MSP Coins 0 00 Cash D
544. ters V 4 Name can not contain Request Name lt gt special characters V Textbox E172 Cognos ReportNet PS amp R If a Job ID has been deleted Error E172 No Job Error on the Reporting side there History found for the job will be no history of that job with Job ID job ID gt E310 Filter by FYE Date FI MAC The day selected must be in Error E310 date is Checkbox Day Parent the month selected not a valid date Drop Down Menu Provider E311 Exclude Checkbox CMS FI MAC At least one provider s Error E311 At least one Parent Exclude checkbox must not provider s Exclude Provider be selected checkbox must not be selected E312 Change Periods with All If one service period s To Error E312 Period Specific Dates Apply date is populated it must be service dates do not have button greater than or equal to its a valid date range From corresponding From date from date To to date E312 Paid Date From Date All Entry must be less than or Error E312 Paid Dates equal to the Paid Date To do not have a valid date Date range From from dates To to dates E312 Paid Date To Date All Entry must be greater than Error E312 Paid Dates or equal to the Paid Date do not have a valid date From Date range From from dates To to dates User Manual February 2009 Version No 2 0 Error Messages C 41 Provider Statistical and Re
545. tet Nec DCN Pint Onti amp Mec Rerd s HE Numc Recpt Dt Paid Ot Service From Service Thru CAMPF 20409076 128804 127000006006 14700000 00 0541254604 09 17 04 eaves 011404 01 14 04 COCHH 20419356319104 128000000000 0957739824 9 24 04 05 31 04 01 26 04 01 27 04 Monthly Totals for PETERBORO GENERAL HOSPITAL for service month end 1 31 04 Feb 7 2007 su Free Rev Code HCPCS Units Charges Trans Type c Pius NG 14000 zm 75708 3126300 0635 3005 44305 HCPCS Tatak 2 1 705 05 TOTAL 2 1 705 05 mhay RevCode HCPCS Unis Charges Procesor D 14000 9052 4403 0305 85610 68 00 0341 75708 126300 0635 soos 944305 HCPCS Total 3 5177405 TOTAL 4 1 772 08 HCPCS Tatat 5 3480 10 TOTAL 5 5348413 Gross Reim Cash Deduct Blood Deduct Coins MSP Pac Red Net Raimb Gross Reimb Cash Deduct Sood Deduct Coins Ms Psyc Red Net Reimb Reimbursements Gross Reim LESS Cash Deduct Sood Deduct Coins Paye Red Net Reimb 100 00 000 356 02 1 053 02 56 19 3 263 29 200 00 s020 752 04 2 13822 Page 1 Report 0044202 Report Type 13A Paid Dates 01 01 04 to 10 01 06 Additional Information MS Cash Deduct MS Blood Deduct MS Coins Claim interest Claim Report Splits MSP Cash Dedect MS Blood Deduct MS Coins Cam interest Cam Report Splits Additional information MS Cash Deduct MS Blood Dedu
546. the calendar Scroll through the months and select the date to use Click Apply to apply the dates to all providers for the From and To dates for each of the four reporting periods Period n To Optional Type the end date in MM DD YYYY format for each of the four reporting periods to assign the reporting period range individually or click the calendar icon to select the end date using the calendar Scroll through the months and select the date to use Click Apply to apply the dates to all providers for the From and To dates for each of the four reporting periods Update Service Dates by Provider s Provider ID5 From Optional Type the start date in MM DD YYYY format for each of the four reporting periods to assign the reporting period range individually for a provider Provider ID To Optional Type the end date in MM DD YYYY format for each of the four reporting periods to assign the reporting period range individually for a provider Exclude Optional Select the Exclude check box to exclude any provider or reporting periods from the report s Select Paid Dates Include all Paid Dates at time of report generation Required if the Select Paid Dates option is not selected Select the I nclude all Paid Dates at time of report generation option to include all available paid dates in the report Paid Dates From Required if the I nclude all Paid Dates at the time of report generation option is not selected T
547. the first three positions 055 are rolled up User Manual February 2009 Version No 2 0 Report Data B 109 Provider Statistical and Reimbursement System Report Type Data Element Description 329 SCIC PEP 056X All revenue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 SCIC PEP 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 SCIC PEP 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 SCIC PEP 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 SCIC PEP 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 SCIC PEP 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 SCIC PEP 0623 Displays by itself These fields are not populated on this report 329 SCIC PEP All other Rev Codes display These fields are not populated on this report as they come in on the claim they do not roll up 329 SCIC 0023 Does not display These fields are not populated on this re
548. ting purposes 11K CLAIMS Currently this field has no cost report usage 11K UNITS The number of units applicable to each revenue code Note for accommodations revenue codes this may include non covered days 11K CHARGES The charges applicable to each revenue code 11K REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 11K DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 11K TOTAL ACCOMODATI ONS This category may include provider liable days that are non covered days This category may be used to prorate the Medicare Days field for cost reporting purposes 11K TOTAL ANCI LLARY All Medicare covered charges associated with revenue codes designated as ancillary 11K TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as routine and ancillary 11K HOSPITAL SPECIFIC This line plus any federal specific amounts are the total DRG amounts other than outlier 11K FEDERAL SPECIFIC This line plus any hospital specific amounts are the total DRG amounts other than outlier User Manual February 2009 Version No 2 0 Report Data B 11
549. tion Detail Report Template PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Program ID REDESIGN PAYMENT RECONCILIATION REPORT Page Service Month End 02 23 04 OUTPATIENT AMBULANCE BLEND EFFECTIVE 04 01 02 Report OD44202 Report Run Date 02 07 07 Report Type 132 Provider FYE 12 31 Paid Dates 01 01 04 to 10 01 08 Provider Number T00007 PETERBORO GENERAL HOSPITAL PE nm mmm mm vv rt FI Patet Nmc SOM A Bil Freq 1 GrossFee Gross Cash Blood Psyc Line mem Gross Remb 238535 MS Cash Deduct 069 DCN 2048159246204 Trans Type RevCode HCPCS Units Charges Aa Remp Deduct Degert MS MP ng Samb HE MS Blood Deduct 0 09 Pant Cagri amp 129000000000 Processor ID 14000 0540 AD 1 6 585 00 270 27 2 645 000 000 25112 0 00 1 455 33 MS Coins 0 00 Med Rcrd i 16100000000 Zip Code 32701 0540 ADGE 6 16200 1024 8150 000 000 2597 000 55 93 Cash Deduct 200 Claim imerest 0 00 HC Num 262667837A ee eect 0 00 Claim Report Spits 137 Recot Dt 05 03 04 Total Amb Trips 658500 27227 230645 000 0 09 851 72 000 145533 Coins 877 03 Paid Ot 05 17 04 MSP 200 Service Frome 02 20 04 Total Amb Mies amp 6200 084 8199 000 200 2597 SOLO 5533 Pe Red Service Thru 02 20 04
550. tion of 10096 fee reimbursed ambulance services Sorted by trips and mileage 12Z TOTAL AMBULANCE TRIPS Accumulated number of trips from paid claims 12Z TOTAL AMBULANCE MILES Accumulated number of miles from paid claims 12Z TOTAL GROSS FEE SCHEDULE AMT This is an accumulation of 10096 fee reimbursed ambulance services 12Z REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4or a complete listing of revenue codes 12Z DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 12Z TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 12Z GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 12Z CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 12Z BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 12Z COI NSURANCE The actual coinsurance amount from the paid claim record 12Z NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 12Z NET REI MBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include
551. tion process The following buttons are only available to FI MAC administrative users e Decline Clicking Decline allows the FI MAC administrative user to decline a report request e Modify Clicking Modify allows the FI MAC administrative user to change a report request The following buttons are only available to CMS users granted access to the Administration pages e Add Clicking Add allows the CMS user to add information to the PS amp R System database e Search Clicking Search allows the CMS user to search for information in the PS amp R System database e Update Clicking Update allows the CMS user to update information in the PS amp R System database 2 3 8 Keyboard Shortcuts The following keyboard shortcuts can be entered to perform the same function as clicking the corresponding button throughout the PS amp R System Button Keyboard Equivalent ALT L gt gt ALT R Add ALT A Back ALT B Continue ALT C Decline ALT D Modify ALT M Refresh ALT R Reset ALT R Search ALT S Submit ALT S Update ALT U User Manual System Overview and Common Features February 2009 Version No 1 2 13 Provider Statistical and Reimbursement System 2 3 9 Special Characters The following special characters can be used in any data entry fields within the PS amp R System e amp ampersand e question mark e equals sign e period e colon e slash e space e comma e at sign
552. tistical and Reimbursement System Report Type Data Element Description 329 FULL CLAIM INTEREST PAYMENTS Part B claim interest payment for full episode 329 LUPA EPISODES WITHOUT OUTLIER This is Part B number episodes without outlier for LUPA 329 LUPA HIPPS REIMBURSEMENT This is Part B HHPPS reimbursement without outlier for LUPA WITHOUT OUTLIER 329 LUPA EPISODES WITH OUTLIER This is Part B number episodes with outlier for LUPA 329 LUPA HIPPS REIMBURSEMENT WITH This is Part B HHPPS reimbursement with outlier for LUPA OUTLIER 329 LUPA OUTLIER REIMBURSEMENTS This is Part B outlier reimbursement for LUPA 329 LUPA PROSTHETI C ORTHOTIC This is Part B P amp O for LUPA DEVICES 329 LUPA DME This is Part B DME for LUPA 329 LUPA OXYGEN This is Part B oxygen for LUPA 329 LUPA OTHER FEE REI MBURSEMENTS This is Part B other fee LUPA 329 LUPA GROSS REIMBURSEMENT Part B Gross Reimbursement for LUPA 329 LUPA DEDUCTIBLES This is Part B deductibles for LUPA 329 LUPA COINSURANCE This is Part B coinsurance for LUPA 329 LUPA NET MSP PAYMENTS This is Part B MSP recon for LUPA 329 LUPA MSP RECONCILIATION This is Part B net MSP payment for LUPA 329 LUPA OTHER ADJUSTMENTS This is Part B other adjustments for LUPA 329 LUPA NET REIMBURSEMENT This is Part B net reimbursement for LUPA 329 LUPA CLAIM INTEREST PAYMENTS Part B Claim
553. to the claims payment timeliness CPT provisions 760 CLAIMS Currently this field has no cost report usage 760 UNITS The number of units applicable to each revenue code 760 CHARGES The charges applicable to each revenue code 760 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 760 DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 760 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 760 GROSS REI MBURSEMENT The gross amount paid to the provider on a claim by claim basis 760 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 760 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 760 COINSURANCE The actual coinsurance amount from the paid claim record 760 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 760 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc
554. ts are first allocated to the extent of any deductibles or coinsurance User Manual February 2009 Version No 2 0 Report Data B 9 Provider Statistical and Reimbursement System Report Type Data Element Description 119 MSP PASS THRU RECONCILIATION This field is informational only and should not be included in the cost report This amount occurs in cases where Medicare has made no payment on the claim yet classifies it as PR Partial Recovery because of the estimated pass through payments The actual pass through amounts will be determined in the cost report The MSP Pass Thru Reconciliation amount must be ignored for cost reporting 119 OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 119 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 119 CALCULATED NET REIMB FOR PIP CLAIMS For intermediary use Indicates that provider received PIP payments May be used to identify duplicate payments 119 ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Tr
555. ts in this field directly to the cost report worksheet E 1 in addition to the PIP payments Ensure the amounts from reports 11A 18A 21A 118 and all other inpatient reports are transferred to the cost report 110 CLAIM INTEREST PAYMENTS Sum of interest paid on claims due to untimely claims processing Currently this field has no cost report usage 110 IRF PENALTY AMOUNT The 2596 penalty assessed for failure to submit IRF PAI data timely 110 LTCH SHORT STAY OUTLIER PAYMENTS The per diem payments made under PPS to the provider for a patient s stay in the facility prior to being transferred to another facility These payments are included in the net reimbursement field This field is shown for informational purposes only 110 CAP FED SPECIFIC 10096 Note This field equals the federal specific field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period This field should be used by hold harmless providers only 110 CAP OUTLIER 10096 Note This field equals the outlier field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period User Manual February 2009 Version No 2 0 Report Data B 3 Provider Statistical and Reimbursement System Report Type Data Element Description 110 DRG CMG WEIGHT This is the ac
556. tual weight of the DRG CMG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS operating payments made to a specific provider 110 WEIGHT DISCHARGES This is the actual weight non transfer adjusted of the DRG determined by the PPS Pricer program divided by the discharges 110 DISCHARGE FRACTION For transfer cases the billed days are divided by the average length of stay for the DRG and the result is entered in this field The amounts in this field cannot exceed 1 0000 For non transfer cases the amount 1 0000 will always appear in this field 110 DRG WEIGHT FRACTION This is the actual weight of the DRG determined by the PPS Pricer program The aggregate amount in this field for a provider s fiscal year may be used to calculate a case mix index CMI for PPS operating payments made to a specific provider 110 DRG WEIGHT FRACTION DISCHARGES This field reflects the DRG weight times the discharge fraction divided by the discharges This amount can be used to calculate a transfer adjusted case mix 11A ACTUAL CLAIM PAYMENTS FOR PIP This field reflects the actual payments made on a claim basis on PIP claims such as operating Outlier and ECT the MSP LCC net reimbursement is not paid on a PIP claim so is reflected in this field as a negative amount Transfer all amounts in this field
557. uch as bi weekly pass through payments lump sums and financial adjustments etc 712 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions User Manual February 2009 Version No 2 0 Report Data B 69 Provider Statistical and Reimbursement System Report Type Data Element Description 732 CLAIMS Currently this field has no cost report usage 732 UNITS The number of units applicable to each revenue code 732 CHARGES The charges applicable to each revenue code 732 REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 732 DESCRIPTION The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 732 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 732 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 732 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 732 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 732 COINSURANCE The actual c
558. ue code lines These fields are not populated on this report where the first three positions 056 are rolled up 329 LUPA 057X All revenue code lines These fields are not populated on this report where the first three positions 057 are rolled up 329 LUPA 058X All revenue code lines These fields are not populated on this report where the first three positions 058 are rolled up 329 LUPA 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 LUPA 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 LUPA 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 LUPA 0623 Displays by itself These fields are not populated on this report 329 LUPA All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 PEP 0023 Does not display These fields are not populated on this report 329 PEP 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 PEP 0274 Displays by itself These fields are not populated on this report 329 PEP 029X All revenue codes lines These fields are not populated on this report where the fir
559. uests can be saved To access a saved report select the Favorite Requests option from the Request Report menu Refer to Section 3 5 Favorite Requests for additional information 11 Click Submit to submit the report request or click Back to return to the previous page Once Submit is selected the report request is submitted and the Provider Statistical and Reimbursement Home page appears Reports generated from this page can be viewed by accessing the Summary Report Inbox option from the Report Inbox menu User Manual Performing Tasks in the PS amp R February 2009 Version No 2 0 3 14 Provider Statistical and Reimbursement System 3 4 Request Detail Reports Perform the following steps to request detail reports 1 Select the Request Detail option from the Request Report menu The following page appears Provider Statistical amp Reimbursement System Site Map Announcements FAQ Help Logout GLOBAL FI MAC 14000 User ID TRTEST17 Thursday August 23 Detail Report Request Home Report Inbox Request Report Favorite Requests Request Summary Request Detail Detail Report Request 1 Select Provider s Search T00006 HALF PIPE HOSPITAL SYSTEM T00007 PETERBORO GENERAL HOSPITAL T00026 MOUNTAIN TOP MEDICAL CENTER T00028 PARROTHEAD MEDICAL CENTER T00044 SACRED SISTERS MEDICAL CENTER T01301 SHATTERED HEART AT THE OAKS id 701433 MISS DAISYS COMMUNITY MENTAL HEAL T01514 PETERBORO HOSPICE T0230
560. ulance Blend Effective 04 01 02 13Z 5 25 5 5 3 SNF Ambulance Blend Effective 04 01 02 22Z sees 5 25 5 5 4 SNF Ambulance Blend Effective 04 01 02 23Z sees 5 25 5 5 5 ASC and ASC Fee Schedule Ambulance Blend Effective 04 01 02 832 tete dede a e lea pide d ade esee 5 25 5 5 6 Critical Access Hospital Ambulance Blend Effective 04 01 02 85 Z 0 o e teaw cil ed oce ee bre oet na denda Crude rio Do 5 25 5 6 xx2 Vaccines Report Template 2 2 aawana awan aana nan eene nemen nens 5 25 5 6 1 Inpatient Part B Vaccine 122 2 3 nemen 5 28 5 6 2 Outpatient Part B Vaccine 132 nemen 5 28 5 6 3 Outpatient Other Vaccines 142 sss emen 5 28 5 6 4 SNF Inpatient Vaccine Part B 10096 Reasonable Cost 222 5 28 5 6 5 SNF Outpatient Vaccine Part B 10096 Reasonable Cost 232 5 28 5 6 6 Home Health Vaccine Part B 10096 Reasonable Cost 342 5 28 5 6 7 Clinic Rural Health Vaccine Part B 10096 Reasonable Cost 712 5 28 User Manual February 2009 Version No 2 0 Table of Contents iv Provider Statistical and Reimbursement System 5 6 8 Federally Qualified Health Center Vaccine Part B 10096 Reasonable COSE 732 a oe t redo pius cubi ese oes 5 28 5 6 9 Rehabilitation Facility Vaccine Part B 10096 Reasonable Cost 742 5 29 5 6 10 Comprehensive Outpatient Rehabilitation Facil
561. ulated on this report where the first three positions 058 are rolled up 329 FULL 059X All revenue code lines These fields are not populated on this report where the first three positions 059 are rolled up 329 FULL 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 329 FULL 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 329 FULL 0623 Displays by itself These fields are not populated on this report 329 FULL AII other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 329 LUPA 0023 Does not display These fields are not populated on this report 329 LUPA 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 329 LUPA 0274 Displays by itself These fields are not populated on this report 329 LUPA 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up 329 LUPA 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 329 LUPA 043X All revenue code lines These fields are not populated on this report where the first three positions 043 are ro
562. under the OPPS regulations This is an information only field 71P CLAI MS Currently this field has no cost report usage 71P UNITS The number of units applicable to each revenue code 71P CHARGES The charges applicable to each revenue code 71P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 71P DESCRIPTI ON The description of each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing and a description of all revenue codes 71P TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 71P GROSS APC PAYMENT The gross APC amount paid to the provider on a claim by claim basis as determined by the OPPS Pricer 71P OUTLIER The outlier portion of the OPPS payment for the APC 71P GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 71P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 71P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 71P COINSURANCE The actual coinsurance amount from the paid claim record 71P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 71P MSP REC
563. under the Prospective Payment System 410 TOTAL OPERATI NG PAYMENTS This is the sum of the operating amounts for HSP FSP outlier DSH LI P IME teaching adjustment new technology IPF ECT and exception payments 410 HOSPITAL SPECIFIC This is the hospital specific portion of the PPS payment for capital The field will be zero for providers paid based on the hold harmless old capital or the hold harmless 100 percent federal method and for new hospitals during their first two years of operation 410 FEDERAL SPECIFIC This field includes the federal portion of the PPS payment for capital This field will also include the new capital amount for hospitals paid under the hold harmless old capital method 410 OUTLIER This field will show the outlier portion of the PPS payment for capital 410 HOLD HARMLESS This field shows the hold harmless amount paid for old capital based on the hold harmless old capital method 410 DSH This is the disproportionate share portion of the PPS capital payment 410 INDIRECT MEDI CAL EDUCATION This is the indirect medical education adjustment payment to PPS teaching hospitals applicable to PPS capital payments 410 EXCEPTI ONS This is the per discharge exception interim payment for capital related costs that qualifying hospitals are entitled to receive in accordance with Medicare payment policy 410 TOTAL CAPITAL PAYMENTS
564. unt paid to the provider on a claim by claim basis 82P CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 82P BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 82P COINSURANCE The actual coinsurance amount from the paid claim record 82P NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 82P MSP RECONCILIATION This field is the accumulation of the difference between the Medicare allowable amount and the actual Medicare reimbursement This occurs in situations where there is OTAF or MSP LCC 82P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 82P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 58 Provider Statistical and Reimbursement System Report Type Data Element Description 82P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT
565. untimely claims processing Currently this field has no cost report usage 11V IRF PENALTY AMOUNT The 25 penalty assessed for failure to submit IRF PAI data timely 11V LTCH SHORT STAY OUTLIER PAYMENTS The per diem payments made under PPS to the provider for a patient s stay in the facility prior to being transferred to another facility These payments are included in the net reimbursement field This field is shown for informational purposes only User Manual February 2009 Version No 2 0 Report Data B 32 Provider Statistical and Reimbursement System Report Type Data Element Description 11V CAP FED SPECIFIC 10096 Note This field equals the federal specific field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period This field should be used by hold harmless providers only 11V CAP OUTLIER 10096 Note This field equals the outlier field for providers that were paid based on the hold harmless 100 percent federal method method B for the entire reporting period 11V DRG CMG WEIGHT This field does not apply and will be zero 11V WEIGHT DISCHARGES This field does not apply and will be zero 11V DISCHARGE FRACTION This field does not apply and will be zero 11V DRG WEIGHT FRACTION This field does not apply and will be zero 11V DRG WEIGHT FRACTION
566. urable medical equipment charges where the first three positions 029 are rolled up 399 SCIC 042X All revenue code lines Total physical therapy covered charges during SCIC only where the first three positions 042 episode are rolled up 399 SCIC 043X All revenue code lines Total occupational therapy covered charges during SCIC only where the first three positions 043 episode are rolled up 399 SCIC 044X All revenue code lines Total speech therapy covered charges during SCIC only where the first three positions 044 episode are rolled up 399 SCIC 055X All revenue code lines Total covered charges related to nursing services during SCIC where the first three positions 055 only episode are rolled up 399 SCIC 056X All revenue code lines Total covered charges related to medical social services during where the first three positions 056 SCIC only episode are rolled up User Manual February 2009 Version No 2 0 Report Data B 157 Provider Statistical and Reimbursement System Report Type Data Element Description 399 SCIC 057X All revenue code lines Total covered charges related to home health aide services where the first three positions 057 during SCIC only episode are rolled up 399 SCIC 058X All revenue code lines Part B other visits without outlier where the first three positions 058 are rolled up 399 SCIC 059X All
567. urs in situations where there is OTAF or MSP LCC 76P OTHER ADJUSTMENTS This amount should be zero If not please investigate the amount by using Detail Other Reports 76P NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc User Manual February 2009 Version No 2 0 Report Data B 56 Provider Statistical and Reimbursement System Report Type Data Element Description 76P CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 76P ELECTED COINSURANCE The OPPS reduced coinsurance amount that the provider has elected to receive under the OPPS regulations This is an information only field 81P CLAI MS Currently this field has no cost report usage 81P UNITS The number of units applicable to each revenue code 81P CHARGES The charges applicable to each revenue code 81P REV CODE Each revenue code and its associated covered units and charges See IOM 100 04 Chapter 25 Section 60 4 for a complete listing of revenue codes 81P DESCRIPTION The description of each revenue code and its associated covered units and charges See OM 100 04 Chapter 25 Section 60 4
568. ursement System 2 2 1 4 FAQ The FAQ hyperlink when selected displays a list of frequently asked questions relating to the PS amp R System Click the question hyperlink to display the answer to the question Click Back to Top to return to the top of the page The FAQ page follows Exhibit 2 6 FAQ Page Provider Statistical amp Reimbursement System Home Report Inbox Request Report PS amp R Frequently Asked Questions This section provides answers to the following frequently asked questions organized into general technical reimbursement and provider specific questions Frequently Asked Questions 1 General Questions 1 01 What does PS amp R stand for What is the PS amp R 1 02 What is a Cost Report 1 03 When must Cos be filed 1 04 What is IACS 1 05 How do I get to IACS And where do I find more information about IACS 1 06 Can I have more than one user in my organization request PS amp R reports 1 07 What do I do if I have a change of staff How can I prevent that person from accessing the PS amp R 1 08 Who do I call if I have questions or I am having problems navigating through the system 1 09 What do I do if one of my providers is not available in the list of providers in the PS amp R system 1 10 Will my Fiscal Intermediary Medicare Administrative Contractor continue to send me my PS amp R reports 1 11 What is the turn around time for receiving detail requests from Fiscal Intermediary
569. ustment Value Code 19 amount shown on the PS amp R are estimated payments made on a bill by bill basis by the PPS pricer program For cost reporting purposes the amount must be recomputed 110 NEW TECHNOLOGY Summarizes new technology payments Value code 77 made under the Prospective Payment System 110 IPF ECT Summarizes IPF ECT Inpatient Psych Facility Electro Convulsive Therapy payments made under the Prospective Payment System 110 TOTAL OPERATI NG PAYMENTS This is the sum of the operating amounts for HSP FSP outlier DSH LI P IME teaching adjustment new technology IPF ECT and exception payments 110 HOSPITAL SPECIFIC This is the hospital specific portion of the PPS payment for capital The field will be zero for providers paid based on the hold harmless old capital or the hold harmless 100 percent federal method and for new hospitals during their first two years of operation 110 FEDERAL SPECIFIC This field includes the federal portion of the PPS payment for capital This field will also include the new capital amount for hospitals paid under the hold harmless old capital method 110 OUTLIER This field will show the outlier portion of the PPS payment for capital 110 HOLD HARMLESS This field shows the hold harmless amount paid for old capital based on the hold harmless old capital method 110 DSH This is the disproportionate share portion of the PPS c
570. ve Warning Requests Select been changed by the FI MAC The selected Service Service Period admin display warning Periods may be outside Date s Screen message after the admin the requestor s selected clicks Continue from the range Select Service Period Date s The new Service Periods screen may contain data which does not belong to the requestor Do you wish to continue W008 Parent Provider is no Parent If you are requesting a Warning W008 Service longer an owner of a Provider report from when a parent dates requested do not child provider owned a child coincide with requestor provider it must be in the access rights for Provider range of when the Provider ID These dates will be owned the child modified on the Confirm Report Request screen to reflect valid access dates Do you wish to Continue W009 CSV Format All If the Report 1000 was Warning W009 The 1000 Selected selected from the Select report will not generate in Report s screen the PDF CSV format Do you wish format should be selected to continue W009 PDF amp CSV Format All If the Report 1000 was Warning W009 The 1000 Selected selected from the Select report will not generate in Report s screen the PDF CSV format Do you wish format should be selected to continue User Manual February 2009 Version No 2 0 Error Messages C 45 Provider Statistical and Reimbursement System
571. ve in accordance with Medicare payment policy 11R TOTAL CAPITAL PAYMENTS This is the sum of the capital amounts for HSP FSP outlier hold harmless disproportionate share adjustment indirect medical education and exception payments 11R GROSS REIMBURSEMENT This amount is the sum of total operating and total capital payments 11R DEVICE CREDIT This amount represents the credit that a provider received to replace a medical device that may have been defective or under warranty This amount can be identified with a value code of FD on the claim 11R CASH DEDUCTIBLE The sum of actual cash deductible amount from the paid claim records 11R BLOOD DEDUCTIBLE The sum of actual blood deductible amount from the paid claim records 11R COINSURANCE The sum of actual coinsurance amount from the paid claim records 11R NET MSP PAYMENTS The sum of net payments made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 11R MSP PASS THRU RECONCILIATION This field is informational only and should not be included in the cost report This amount occurs in cases where Medicare has made no payment on the claim yet classifies it as PR Partial Recovery because of the estimated pass through payments The actual pass through amounts will be determined in the cos
572. venue code lines These fields are not populated on this report where the first three positions 059 are rolled up 339 FULL 060X All revenue code lines These fields are not populated on this report where the first three positions 060 are rolled up 339 FULL 062X All revenue code lines These fields are not populated on this report where the first three positions 062 are rolled up 339 FULL 0623 Displays by itself These fields are not populated on this report 339 FULL All other Rev Codes display as These fields are not populated on this report they come in on the claim they do not roll up 339 LUPA 0023 Does not display These fields are not populated on this report 339 LUPA 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 LUPA 0274 Displays by itself These fields are not populated on this report 339 LUPA 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 116 Provider Statistical and Reimbursement System Report Type Data Element Description 339 LUPA 042X All revenue code lines These fields are not populated on this report where the first three positions 042 are rolled up 339 LUPA 043X
573. venue codes 23Z TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as ancillary 23Z GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 23Z CASH DEDUCTIBLE The actual cash deductible amount from the paid claim record 23Z BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 23Z COINSURANCE The actual coinsurance amount from the paid claim record 23Z NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 23Z NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 23Z CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 83Z CLAI MS Currently this field has no cost report usage 83Z UNITS The number of units applicable to each revenue code 83Z CHARGES The charges applicable to each revenue code 83Z GROSS FEE AMT This is an accumulation of 10096 fee reimbursed ambulance services Sorted by trips and mileage 83Z TOTAL AMBULANCE TRI PS Accumulated number of trips from paid claims 83Z TOTAL AMB
574. vider FYE 09 30 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM PROVIDER SUMMARY REPORT Page 1 CONSOLIDATED SUMMARY OF ALL REPORT TYPES Report OD44203 THIS DATA IS INFORMATIONAL ONLY NOT ALL ITEMS ARE USED FOR COST REPORTS Report Type 1000 Provider Number T00028 PARROTHEAD MEDICAL CENTER REPORT TYPE INPATIENT REPORTS TOTAL OUTPATIENT REPORTS excluding MSP LCC TOTAL TOTAL Feb 1 2007 110 nA 130 135 13P SERVICES APPLIED FOR THE PERIODS 01 01 2004 12 31 2004 CHARGES GROSS DEDUCTIBLES COINSURANCE MSP ESRD MSP OTHER OTHER PSYCH NET REIMBURSEMENT ROCTN NTWK ADJUSTMENTS REDUCTION REIMBURSEMENT PYMTS 83 797 15 23 678 99 1 752 00 657 00 0 00 0 00 0 00 0 00 0 00 21 269 99 2 582 18 5 056 98 876 00 0 00 1 359 85 0 00 0 00 2 376 80 0 00 445 33 86 479 33 528 737 97 2 628 00 657 00 1 359 85 0 00 0 00 2 376 80 0 00 21 716 32 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 2 351 52 636 90 0 00 0 00 145 01 0 00 0 00 0 00 0 00 493 89 13 183 12 5247459 0 00 829 22 0 00 0 00 0 00 0 00 0 00 1 645 37 15 534 64 3 113 49 0 00 829 22 145 01 0 00 0 00 0 00 0 00 2 13926 102 013 97 31 851 46 2 628 00 1 486 22 1 504 86 0 00 0 00 2 376 80 0 00 23 855 58 SERVICES APPLIED FOR THE PERIODS 01 01 2005 12 31 2005 CHARGES GROSS DEDUCTIBLES COINSURANCE MSP ESRD MSP OTHER OTHER PSYCH NET REIMBURSEMENT ROCTN NTWK ADJUSTMENTS REDUCTION REIMBURSEMENT PYM
575. vider Number T00044 SACRED SISTERS MEDICAL CENTER Patat Nme COHEA Bill Freq DCN 20455543043505 Trans Type Pang Cntri 25000000009 Processor ID Med Rerd amp 116000000909 HIC Num 1991789654 Recpt Ot 05 17 04 Paid Dt 05 31 04 Service From 05 11 04 Service Thru 05 11 04 Patat Nme EPPS Bill freg DCN 204428503043505 Trans Type Pang Cntri 8 M2S000000000 Processor ID Med Rerd st M34000000900 HIC Num 0785510734 Racpt Ot 05 17 04 Paid Ot 05 31 04 Service From 05 11 04 Service Thru 05 11 04 1 14000 PAYMENT RECONCILIATION REPORT OUTPATIENT COST REIMBURSED Monthly Totals for SACRED SISTERS MEDICAL CENTER for service month end 5 31 04 TOTAL Feb 7 2007 Rev P Gros Cah Blood Psyc Line Item Code CPCS Units Changes Rumb Deduct Deduct MSP Rod Raimb 0301 83880 O 0 00 0 00 0 00 0 00 0 00 000 0 00 0301 e4484 0 0 00 0 00 0 00 000 000 000 000 TOTAL 0 so DO 000 000 000 000 000 000 Rev Gros Cah Blood Psyc Lineitem Code CPCS Units Charges pais Deduct Deduct E MSP Rod Raimb 0301 84484 O 00 00 00 000 10 00 0 00 TOTAL 0 so DO 000 000 000 000 00 000 Gross Cash Blood Une Item Units Charges m Deduct Ded Coins MP Psyc Red faimb 000 000 0 00 0 00 2 00 000 0 00 PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM Reimbursements Gross Raimb 0 00 LESS Cash Deduct 200 Blood Deduct 200 Coins sano MP 000 Psyc Rad Net Rend pati Gros
576. vider liable days that are non covered days This category may be used to prorate the Medicare Days field for cost reporting purposes 118 TOTAL ANCILLARY All Medicare covered charges associated with revenue codes designated as ancillary 118 TOTAL COVERED CHARGES All Medicare covered charges associated with revenue codes designated as routine and ancillary 118 HOSPITAL SPECIFIC This line plus any federal specific amounts are the total DRG amounts other than outlier 118 FEDERAL SPECIFIC This line plus any hospital specific amounts are the total DRG amounts other than outlier 118 OUTLIER Summarizes cost outlier payments Value code 17 made under the Prospective Payment System 118 DSH LIP The DSH LIP amount value code 18 shown on the PS amp R report represents interim payments calculated by the PPS Pricer program For cost reporting purposes the DSH LIP amount must be recomputed for qualifying hospitals 118 IME TEACHING ADJ Indirect medical education Teaching adjustment Value Code 19 amount shown on the PS amp R are estimated payments made on a bill by bill basis by the PPS Pricer program For cost reporting purposes the amount must be recomputed 118 NEW TECHNOLOGY Summarizes new technology payments Value code 77 made under the Prospective Payment System 118 IPF ECT Summarizes IPF ECT Inpatient Psych Facility Electro Convulsive Therapy
577. vides diagnostic therapeutic both surgical and nonsurgical and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization Outpatient Services A service provided in one day 24 hours at a hospital outpatient department or community mental health center Part A Part A is the hospital insurance portion of Medicare It was established by 1811 of Title XVIII of the Social Security Act of 1965 as amended and covers inpatient hospital care skilled nursing facility care some home health agency services and hospice care Part B Medicare Supplementary Medical Insurance also referred to as SMI Medicare insurance that pays for inpatient hospital stay care in a skilled nursing facility home health care and hospice care Part B is the supplementary or physicians insurance portion of Medicare It was established by 1831 of the Title XVIII of the Social Security Act of 1965 as amended and covers services of physicians other suppliers outpatient care medical equipment and supplies and other medical services not covered by the hospital insurance part of Medicare PHI Personal Health Information or Protected Health Information User Manual February 2009 Version No 2 0 Glossary D 6 Provider Statistical and Reimbursement System Term Definition Portable Document Format PDF A file format that has captured all the elements of a
578. with revenue codes designated as ancillary 710 GROSS REIMBURSEMENT The gross amount paid to the provider on a claim by claim basis 710 CASH DEDUCTI BLE The actual cash deductible amount from the paid claim record 710 BLOOD DEDUCTIBLE The actual blood deductible amount from the paid claim record 710 COINSURANCE The actual coinsurance amount from the paid claim record 710 NET MSP PAYMENTS The net payment made by a higher priority payer under the MSP provisions is shown in this field Note Primary payments are first allocated to the extent of any deductibles or coinsurance 710 NET REIMBURSEMENT This amount represents an accumulation of interim payments made on the claims This does not include payments such as bi weekly pass through payments lump sums and financial adjustments etc 710 CLAIM INTEREST PAYMENTS Interest payments are accumulated primarily for the IRS Form 1099 reporting requirements The amounts shown are related to the claims payment timeliness CPT provisions 730 CLAIMS Currently this field has no cost report usage 730 UNITS Revenue Code 520 The number of units applicable to each revenue code 730 UNITS Revenue Code 521 The number of units applicable to each revenue code 730 UNITS Revenue Code 522 The number of units applicable to each revenue code 730 UNITS Revenue Code 524 The number of units applicable to each revenue code 730 UNITS Revenue Code 525 The number of units applicable to each revenue code
579. ws Period n From where n is 1 4 for the number of the corresponding reporting period included in the report e Field names are represented as bold text for example Select the By Service Type option and then select the service type to include in the report e Button names are represented as bold text for example Click OK User Manual Introduction February 2009 Version No 2 0 1 1 Provider Statistical and Reimbursement System 1 2 About this Manual This manual provides detailed instructions for using CMS s PS amp R system The remainder of the document is organized as follows Chapter 2 System Overview and Common Features provides a description of the system in addition to a discussion about features that you find throughout the PS amp R system for example menu options button navigation etc Chapter 3 Performing Tasks in the PS amp R presents the step by step instructions necessary to perform day to day tasks using the PS amp R system for example submitting report requests and viewing resulting reports Chapter 4 Inpatient Reports provides a summary of the processing sequence for claim data for presentation on inpatient reports and provides a description of each inpatient report template in addition to the reports generated based on each template Chapter 5 Outpatient Reports provides a summary of the processing sequence for claim data for outpatient and home health agency reports and provides a desc
580. y do not roll up 339 PEP 0023 Does not display These fields are not populated on this report 339 PEP 027X All revenue code lines These fields are not populated on this report where the first three positions 027 excluding 0274 are rolled up 339 PEP 0274 Displays by itself These fields are not populated on this report 339 PEP 029X All revenue codes lines These fields are not populated on this report where the first three positions 029 are rolled up User Manual February 2009 Version No 2 0 Report Data B 117 Provider Statistical and Reimbursement System Report Type Data Element Description 339 PEP 042X All revenue code lines where the first three positions 042 are rolled up These fields are not populated on this report 339 PEP 043X All revenue code lines where the first three positions 043 are rolled up These fields are not populated on this report 339 PEP 044X All revenue code lines where the first three positions 044 are rolled up These fields are not populated on this report 339 PEP 055X All revenue code lines where the first three positions 055 are rolled up These fields are not populated on this report 339 PEP 056X All revenue code lines where the first three positions 056 are rolled up These fields are not populated on this report 339 PEP
581. y for Provider Selected Service ID contains a non Periods Table numeric character or is not in MM DD YYYY format Service Period All Only numeric characters Error E038 Service E038 From Dates in Date s entry for Provider Selected Service ID contains a non Periods Table numeric character or is not in MM DD YYYY format All Entry must be in Error E038 Service E038 MM DD YYYY format Date s entry for Provider ID contains a non numeric character or is not in MM DD YYYY format All Month Day and Year Error E001 Service Date E001 values must be valid entry for Provider ID 5 contains an invalid month day and or year All Entry must be less than or Error E312 Service date s E312 equal to its corresponding for Provider ID do not Service Period To Date have a valid date range From from date To to date All Entry must be greater than Error E092 Service Periods E092 the previous Service Period overlap and or are not To Date this assures chronological for Provider chronological service ID ID 5 periods and that there are no overlapping service periods All user types Entry is one day greater Warning W004 You have W004 except than previous Service selected non consecutive Freestanding Period To Date this checks service periods for Provider Providers to see if the service periods ID 5 This will exclude are consecutive cost report data from t
582. y the U S Bureau of Census SA System Administrator Skilled Nursing Facility SNF A facility meeting specific regulatory certification requirements that primarily provides inpatient skilled nursing care and related services to patients who require medical nursing or rehabilitative services but does not provide the level of care or treatment available in a hospital Pronounced sniff Social Security Administration SSA The independent agency that operates the various programs funded under the Social Security Act It also determines when an individual becomes eligible for Medicare benefits SSN Social Security Number User Manual February 2009 Version No 2 0 D 7 Glossary
583. you wish to continue Clicking the Continue button will bring user to next request page clicking the Back button will bring user back to the dates page and allow them to make any changes E100 Processing Error PS amp R While pages are processing a user should not click the Back button in the Internet Explorer browser Error E100 Report request must start from the navigation bar Back button processing not allowed after submit is performed E101 All Providers Parent Provider users only or By Provider Type and Filter by FYE Date Checkbox CMS FI MAC Parent Provider Provider type s and FYE date selected must have at least one applicable provider Error E101 No providers of the selected Provider Type s are applicable E101 By Provider Type Drop Down Menu CMS FI MAC Parent Provider Provider type selected must apply to at least one provider applicable to the FI PP Error E101 No providers of the selected Provider Type s are applicable User Manual February 2009 Version No 2 0 Error Messages C 39 Provider Statistical and Reimbursement System ID Form Field User Type Validation Error Message E102 Exclude Checkbox For each provider at least Error E102 All service one service period s periods excluded for Exclude checkbox must not Provider ID 5 be selected E11
584. ype must be option selected but no report selected number s chosen If By Service Type radio Error E034 No reports were E034 button or By Report Type radio button is not clicked this radio button must be clicked selected User Manual February 2009 Version No 2 0 Error Messages C 11 Provider Statistical and Reimbursement System C 9 Detail Report Request Select Service Period s The Detail Report Request Select Service Period s page error and warning messages are presented in the following table Exhibit C 9 Detail Report Request Select Service Period s Page Error and Warning Messages Form Field User Type Validation Error Warning Message ID Update Service All Date field must not be null Error E322 Period 1 Start E322 Dates by Date contains a non numeric Interval character or is not in MM DD YYYY format All Date field must contain only Error E322 Period 1 Start E322 numeric characters Date contains a non numeric character or is not in MM DD YYYY format All Date field entry must be in Error E322 Period 1 Start E322 MM DD YYYY format Date contains a non numeric character or is not in MM DD YYYY format All The date field s Month Day Error E001 Period 1 Start E001 and Year values must be Date contains an invalid valid month day and or year Update Service All All date field entries must Error E069 Service Date s

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