Input/Output Record Layout

130.1 Input/Output Record Layout (Rev. 4393, Issued: 09- 13-19: Effective: 11-25-19, Implementation: 11-25-19) The required data and format for the Hospice Pricer input/output record are shown below: FIELD NAME FIELD LAYOUT POSITION DESCRIPTION NPI X(10) 1-10 Input item: The billing provider's National Provider Identifier, copied from the claim. PROV-NO X(6) 11-16 Input item: The billing provider's CMS Certification Number (CCN), copied from the claim. (FISS crosswalks the CCN based on the NPI submitted by the provider.) FROM- DATE 9(8) 17-24 Input item: The statement covers period “From” date, copied from the claim. Date format must be CCYYMMDD. ADMISSI ON- DATE 9(8) 25-32 Input item: The admission date, copied from the claim. Date format must be CCYYMMDD. Filler x(10) 33-42 PROV- CBSA X(5) 43-47 Input item: The CBSA code used to wage-adjust inpatient levels of care. Copied from the value code G8 amount on the claim BENE- CBSA X(5) 48-52 Input item: The CBSA code used to wage-adjust home levels of care. Copied from the value code 61 amount on the claim PROV- WAGE- IND 99V9(4) 53-58 Output item: The wage index value that corresponds to the PROV-CBSA BENE- WAGE- IND 99V9(4) 59-64 Output item: The wage index value that corresponds to the BENE-CBSA NA Day 1 Add-on Units x(2) 65-66 Input item: The number of days from a prior hospice benefit period if identified by CWF as part of the first 60 days of RHC. NA Day 2 Add-on Units x(2) 67-68 Input item: Not used EOL Day 1 Add- on Units x(2) 69-70 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death. No units input if the lines are not associated with routine home care (revenue code 0651) EOL Day 2 Add- on Units x(2) 71-72 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 1 day. No units input if the lines are not associated with routine home care (revenue code 0651) EOL Day 3 Add- on Units x(2) 73-74 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 2 days. No units input if the lines are not associated with routine home care (revenue code 0651) EOL Day 4 Add- on Units x(2) 75-76 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 3 days. No units input if the lines are not associated with routine home care (revenue code 0651) EOL Day 5 Add- on Units x(2) 77-78 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 4 days. No units input if the lines are not associated with routine home care (revenue code 0651) EOL Day 6 Add- on Units x(2) 79-80 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 5 days. No units input if the lines are not associated with routine home care (revenue code 0651) EOL Day 7 Add- on Units x(2) 81-82 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 6 days. No units input if the lines are not associated with routine home care (revenue code 0651) Filler x(10) 83-92 QIP- REDUCTI ON- IND x 93 Input item: An indicator of whether the hospice's payments are subject to the 2% reduction for not reporting quality data. Copied from field 74 on the Outpatient Provider Specific File. Valid values: blank = no reduction, 1 = 2% reduction applies. See CR 8241 for details. REV1 X(4) 94-97 Input item: Revenue code 0651 (if present) copied from the claim. HCPC1 X(5) 98-102 Input item: HCPCS G code associated with revenue code 0651, copied from the claim. Line Item DOS1 9(8) 103-110 Input item: The line item date of service associated with revenue code 651, copied from the claim. UNITS1 9(7) 111-117 Input item: The number of units associated with revenue code 0651, copied from the claim. This represents the number of days of routine home care to be paid. THEIR- PAY- CHG1 9(6)V99 118-125 Output item: The total payment to be made on the revenue code 0651 line. REV2 X(4) 126-129 Input item: Revenue code 0652 (if present) copied from the claim. HCPC2 x(5) 130-134 Input item: HCPCS G code associated with revenue code 0652, copied from the claim. Line Item DOS2 9(8) 135-142 Input item: The line item date of service associated with revenue code 652, copied from the claim. UNITS2 9(7) 143-149 Input item: The number of units associated with revenue code 0652, copied from the claim. This represents the number of 15 minute increments of continuous home care to be paid. THEIR- PAY- CHG2 9(6)V99 150-157 Output item: The total payment to be made on the revenue code 0652 line. REV3 X(4) 158-161 Input item: Revenue code 0655 (if present) copied from the claim. HCPC3 x(5) 162-166 Input item: HCPCS G code associated with revenue code 0655, copied from the claim. Line Item DOS3 9(8) 167-174 Input item: The line item date of service associated with revenue code 655, copied from the claim. UNITS3 9(7) 175-181 Input item: The number of units associated with revenue code 0655, copied from the claim. This represents the number of days of inpatient respite care to be paid. THEIR- PAY- CHG3 9(6)V99 182-189 Output item: The total payment to be made on the revenue code 0655 line. REV4 X(4) 190-193 Input item: Revenue code 0656 (if present) copied from the claim. HCPC4 x(5) 194-198 Input item: HCPCS G code associated with revenue code 0656, copied from the claim. Line Item DOS4 9(8) 199-206 Input item: The line item date of service associated with revenue code 656, copied from the claim. UNITS4 9(7) 207-213 Input item: The number of units associated with revenue code 0656, copied from the claim. This represents the number of days of general inpatient care to be paid. THEIR- PAY- CHG4 9(6)V99 214-221 Output item: The total payment to be made on the revenue code 0656 line. NA Day 1 Add-on Pay 9(6)V99 222-229 Output item: Not used NA Day 2 Add-on Pay 9(6)V99 230-237 Output item: Not used EOL Day 1 Add-on Pay 9(6)V99 238-245 Output item: Payment associated with the corresponding ADD-ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units) EOL Day 2 Add-on Pay 9(6)V99 246-253 Output item: Payment associated with the corresponding ADD-ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units) EOL Day 3 Add-on Pay 9(6)V99 254-261 Output item: Payment associated with the corresponding ADD-ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units) EOL Day 4 Add-on Pay 9(6)V99 262-269 Output item: Payment associated with the corresponding ADD-ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units) EOL Day 5 Add-on Pay 9(6)V99 270-277 Output item: Payment associated with the corresponding ADD-ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units) EOL Day 6 Add-on Pay 9(6)V99 278-285 Output item: Payment associated with the corresponding ADD-ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units) EOL Day 7 Add-on Pay 9(6)V99 286-293 Output item: Payment associated with the corresponding ADD-ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units) PAY-AMT 9(6)99 294-301 Output item: The sum of all payment amounts returned on this record. RTC XX 302-303 Output item: A return code set by Pricer to define the payment circumstances of the claim or an error in input data. Payment return codes: 00 Home rate returned 73 Low RHC rate applies to all RHC 74 Low RHC rate with EOL SIA 75 High RHC rate applies to some or all RHC 77 High RHC with EOL SIA No rate return error codes: 10 Bad units 20 Bad units2<8 30 Bad CBSA code 40 Bad hospice wage index from CBSA file 50 Bad bene wage index from CBSA file 51 Bad provider number High RHC Days 99 304-305 Output item: The number of high RHC days applied to the claim. This number is placed on the claim as a value code 62 amount. Low RHC Days 99 306-307 Output item: The number of low RHC days applied to the claim. This number is placed on the claim as a value code 63 amount. FILLE R x(8) 308-315