Hospice Help Reference¶

The Hospice payment system is used to reimburse hospice providers for end-of-life care.

[!NOTE] This content is sourced from the official CMS Web Pricer.

I/OCE Integration & Fee Schedule Pricing¶

The Hospice Pricer can be run in tandem with the Integrated Outpatient Code Editor (I/OCE). During I/OCE processing of Hospice claims, the engine contains specific CMS logic designed to remap certain non-payable lines into fee schedule services.

Specifically, if a service code is submitted with Status Indicator M (Not billable to the MAC) but is billed with Revenue Code 0657, the I/OCE remaps the Status Indicator from M to A (Fee Schedule).

The Bedrock Billing Myelin engine supports seamlessly calculating the fee schedule rate (Physician, DME, Ambulance, or Clinical Lab) for these lines in the exact same API call. To enable this fallback fee pricing alongside your Hospice logic, include the price_fee_beta: true property inside your claim's additional_data object and ensure both ["HOSPICE", "IOCE"] are included in your requested process modules.

Output Structure: service_lines¶

Because standard Hospice payments are paid based on billing group rollups (e.g., Revenue Code 0651 paid at a daily rate), the core hospice object does not typically return line-by-line pricing.

However, when this plugin is invoked, an additional service_lines array (mapping to HospiceLineOutput models) is injected into the output. This array tracks line-item reimbursements specifically for the individual rules eligible for fee schedule pricing.

Example Request¶

{
  "claimid": "HOSPICE_CLAIM_001",
  "bill_type": "812",
  "patient_status": "40",
  "modules": ["HOSPICE", "IOCE"],
  "lines": [
    {"service_date": "2025-07-01", "revenue_code": "0651", "hcpcs": "Q5001", "units": 9, "charges": 10000},
    {"service_date": "2025-07-01", "revenue_code": "0551", "hcpcs": "G0299", "units": 3, "charges": 10000},
    {"service_date": "2025-07-01", "revenue_code": "0657", "hcpcs": "99447", "units": 1, "charges": 500}
  ],
  "from_date": "2025-07-01",
  "thru_date": "2025-07-10",
  "los": 10,
  "patient": { "age": 65, "sex": "M", "date_of_birth": "1961-03-24" },
  "billing_provider": {
    "other_id": "010001",
    "contract_id": "0",
    "address": { "zip": "36301", "city": "DOTHAN", "state": "AL", "street": "1108 ROSS CLARK CIRCLE" },
    "facility_name": "SOUTHEAST HEALTH MEDICAL CENTER"
  },
  "principal_dx": { "code": "A021", "poa": "Y" },
  "admit_dx": { "code": "A021", "poa": "Y" },
  "value_codes": [
    {"code": "61", "amount": 35300},
    {"code": "G8", "amount": 35300}
  ],
  "additional_data": {
    "price_fee_beta": true
  }
}

Example Response (hospice block only)¶

{
  "hospice": {
    "claim_id": "HOSPICE_CLAIM_001",
    "calculation_version": "2025.0",
    "total_payment": 2167.06,
    "billing_group_payments": [
      { "hcpcs_code": "None", "revenue_code": "0651", "payment_amount": 2134.59 }
    ],
    "service_lines": [
      {
        "line_number": 1,
        "payment": null,
        "reimbursement_amount": null,
        "coinsurance_amount": null,
        "return_code": null
      },
      {
        "line_number": 2,
        "payment": null,
        "reimbursement_amount": null,
        "coinsurance_amount": null,
        "return_code": null
      },
      {
        "line_number": 3,
        "payment": 32.47,
        "reimbursement_amount": 25.98,
        "coinsurance_amount": 6.49,
        "return_code": {
          "code": "FSPHYS",
          "description": "Applied PFS non-facility rate 32.47 (POS unknown/NA (pos=) -> defaulted to NF) from fee schedule id=37968",
          "explanation": null
        }
      }
    ]
  }
}

0651 Date of service results summary¶

Enter the line item date of service from the revenue code 0651, Routine Home Care, line on the claim.

0651 HCPCS results summary¶

The Q Healthcare Common Procedure Coding System (HCPCS) code from the revenue code 0651, Routine Home Care, line on the claim.

0651 Routine home care¶

The general classification of revenue codes is all that is needed for billing.Enter the date of service, Q Healthcare Common Procedure Coding System (HCPCS) code and units that describes the service location of the routine home care. For a complete list of codes, see Publication. 100-04, Chapter 11, Section 30.3. Note: that since HCPCS codes are not currently used in payment calculation, all HCPC fields on the Web Pricer are optional and may be left blank.

0651 Routine home care results summary¶

The hospice is paid the routine home care rate for each day the patient is under the care of the hospice and not receiving one of the other categories of hospice care.This rate is paid without regard to the volume or intensity of routine home care services provided on any given day and is also paid when the patient is receiving outpatient hospital care for a condition unrelated to the terminal condition.

0651 Units results summary¶

The number of covered units for the revenue code 0651, Routine Home Care, line on the claim.

0652 Continuous home care¶

The general classification of revenue codes is all that is needed for billing.Enter the date of service, Q Healthcare Common Procedure Coding System (HCPCS) code and the sum of the service units from any revenue code 0652 lines on the claim. This represents the number of 15-minute increments of continuous home care provided in the billing period. If entering fewer than 32 units (8 hours) of continuous home care, enter a date in the routine home care window because a day of routine home care payment will apply.

0652 Continuous home care results summary¶

Continuous home care rate is paid during a period of crisis to maintain the terminally ill at home. The continuous home care rate is divided by 24 hours to arrive at an hourly rate. A minimum of 8 hours must be provided during a 24-hour day. The care need not be continuous.Parts of an hour are identified through the reporting of time for continuous home care days in 15-minute increments and these increments are used in calculating the payment rate. Only patient care provided during the period of crisis is to be reported. Payment is based upon the number of 15-minute increments that are billed for 32 or more units.The care must be predominantly nursing care provided by either a registered nurse (RN) or licensed practical nurse (LPN). At least half of the hours of care must be provided by the RN or LPN. Homemaker or home health aide (also known as a hospice aide) services may be provided to supplement the nursing care. Rounding to the next whole hour is no longer applicable. Units should only be rounded to the nearest increment. Billing for CHC should not reflect nursing shifts and non-direct patient increments (e.g., meal beaks, report, education of staff). Continuous home care is not intended to be used as respite care.Continuous home care is not paid during a hospital, skilled nursing facility or inpatient hospice facility stay.

0652 Date of service results summary¶

The line item date of service from the revenue code 0652, Continuous home care, line on the claim.

0652 HCPCS results summary¶

The Q Healthcare Common Procedure Coding System (HCPCS) code from the revenue code 0652, Continuous home care, line on the claim.

0652 Units results summary¶

The number of covered units for the revenue code 0652, Continuous home care, line on the claim.

0655 Date of service results summary¶

The line item date of service from the revenue code 0655, Inpatient respite care, line on the claim.

0655 HCPCS results summary¶

The Q Healthcare Common Procedure Coding System (HCPCS) code from the revenue code 0655, Inpatient respite care, line on the claim.

0655 Inpatient respite care¶

The general classification of revenue codes is all that is needed for billing.Enter the date of service, Q Healthcare Common Procedure Coding System (HCPCS) code and units that describes the service location of the inpatient respite care. This represents the number of days of inpatient respite care provided in the billing period.

0655 Inpatient respite care results summary¶

Inpatient respite care is paid for each day the beneficiary is in an approved inpatient facility and receiving respite care.Paid at a maximum of 5 continuous days, including the admission date but not the discharge date. Exceeding 5 days, payment is at the routine home care rate. More than one respite period is allowable in a single billing period.If the beneficiary dies under inpatient respite care, the day of death is paid at the inpatient respite care rate. Payment at the respite rate is made when respite care is provided at a Medicare or Medicaid certified hospital, SNF, hospice facility, or NF.

0655 Units results summary¶

The number of covered units for the revenue code 0655, Inpatient respite care, line on the claim.

0656 Date of service results summary¶

The line item date of service from the revenue code 0656, General inpatient care, line on the claim.

0656 General inpatient care¶

The general classification of revenue codes is all that is needed for billing.Enter the date of service, Q Healthcare Common Procedure Coding System (HCPCS) code and the service units from the revenue code 0656 line on the claim. This represents the number of days of general inpatient care provided in the billing period.

0656 General inpatient care results summary¶

Payment at the inpatient rate is made when general inpatient care is provided at a Medicare-certified hospice facility, hospital, or skilled nursing facility.

0656 HCPCS results summary¶

The Q Healthcare Common Procedure Coding System (HCPCS) code from the revenue code 0656, General inpatient care, line on the claim.

0656 Units results summary¶

The number of covered units for the revenue code 0656, General inpatient care, line on the claim.

Actual geographic MSA¶

Actual Geographic Metropolitan Statistical Area (MSA), indicates where a provider is located. The Actual Geographic MSA is entered as a 4-digit value, that ranges from 0040-9965. In a rural area, the Actual Geographic MSA is entered as '00' followed by the 2-digit numeric state code. For example, Ohio with state code 36 would be entered as '0036'.

Add-on visit amount¶

The add-on amount to be applied to the earliest line item date with the corresponding revenue code.

Admit date¶

This field requires the date the patient was admitted to the facility (the ADMIT date in FL 12 of the UB 04).

AIDS Add-on Indicator¶

Flag indicating if an AIDS adjustment is applicable.

Bed size¶

The facility bed size is equal to the number of adult hospital beds and pediatric beds available to inpatient lodging. This field must be greater than zero.

Beneficiary CBSA¶

Enter the Core-Based Statistical Area code representing the beneficiary’s site of service, if services were provided in the home. This is the value code 61 amount from the claim.A residence can be an inpatient facility if an individual uses that facility as a place of residence. It is the level of care that is required and not the location where services are provided that determines payment. In other words, if an individual resides in a freestanding facility and requires routine home care, then claims are submitted for routine home care.

Beneficiary core-based statistical area (CBSA)¶

Beneficiary Payment Core-Based Statistical Area (CBSA), used to wage-adjust home levels of care. Hospices shall report the CBSA for the beneficiary's residence on the claim in value code 61.

Beneficiary core-based statistical area (CBSA) results summary¶

Beneficiary Payment Core-Based Statistical Area (CBSA), used to wage-adjust home levels of care.

Bill payment¶

With the exception of payment for physician services, Medicare payment for hospice care is made at one of four predetermined rates for each day that a Medicare beneficiary is under the care of the hospice.

Capital cost-to-charge ratio¶

The capital cost-to-charge ratio is derived from the latest cost report and corresponding charge data from the billing file.For hospitals for which the MAC is unable to compute a reasonable cost-to-charge ratio, it uses the appropriate statewide average cost-to-charge ratio calculated annually by CMS and published in the Federal Register. A provider may submit evidence to justify a capital cost-to-charge ratio that lies outside a 3 standard deviation band. The MAC uses the hospital's ratio rather than the statewide average if it agrees the hospital's rate is justified.

Capital exception payment¶

Exception payments are provided for hospitals with inordinately high levels of capital obligations. The capital exception payment rate is the per discharge exception payment to which a hospital is entitled.

Capital hospital-specific rate¶

The hospital-specific capital rate is the hospital's allowable adjusted base year inpatient capital costs per discharge. This must be present unless a "Y" is entered in the Capital Indirect Medical Education Ratio field; or a "08" is entered in the Provider type field; or a termination date is present in Termination Date field. This field is not used as of October 1, 2002.

Capital indirect medical¶

An adjustment is provided to the Federal rate for indirect costs of medical education of interns and residents. The capital indirect medical education ratio field is the ratio of interns and residents to the hospital's average daily census. It is calculated by dividing the hospital's full-time equivalent total of residents during the fiscal year by the hospital's total inpatient days. This field is relevant for IPPS hospitals and IRFs.

Capital new harmless ratio¶

The new capital hold harmless ratio is the ratio of the hospital's allowable inpatient costs for new capital to the hospital's total allowable inpatient capital costs. This field is updated annually.

Capital old harmless rate¶

The old capital hold harmless rate shows the hospital's allowable inpatient "old" capital costs per discharge incurred for assets acquired before December 31, 1990, for capital PPS.

Capital PPS pay code¶

The capital PPS payment code indicates the type of capital payment methodology for hospitals. "A" indicates hold harmless, cost payment for old capital. "B" indicates hold harmless, 100% federal rate. "C" indicates fully prospective blended rate.

Case-mix-index¶

A hospital's case-mix-index (CMI) represents the average diagnosis-related group (DRG) relative weight for that hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges. CMIs are calculated using both transfer-adjusted cases and unadjusted cases.

Change code for reclass¶

When this field is active, "Y" indicates that the provider's wage index location has been reclassified for the year. "N" indicates that the provider has not been reclassified for the year.

Core-based statistical area (CBSA)¶

A Core-Based Statistical Area (CBSA) is a geographic area defined by the Office of Management and Budget (OMB). The CBSA designation is used to adjust for geographic differences in wages.The term refers collectively to metropolitan and micropolitan statistical areas, which consist of one or more counties (or equivalents) anchored by an urban center of at least 10,000 people plus adjacent counties that are tied to the urban center.

Core-based statistical area / Geographic CBSA¶

A Core-Based Statistical Area (CBSA) is a labor market area definition adopted by CMS based on the delineations defined by the Office of Management and Budget (OMB). A hospital's geographic CBSA is based on its geographic location, irrespective of any reclassification.

Cost¶

The dollar amount determined by the Pricer to be the payment for the visits in each discipline if the claim is paid as a Low Utilization Payment Adjustment (LUPA).

Cost of living adjustment¶

The cost of living adjustment (COLA) factor accounts for a higher cost of living in Alaska and Hawaii. The COLA factor provided to facilities is published annually in the final rule for the prospective payment systems.

Cost-to-charge ratio¶

The cost-to-charge ratio is derived from the latest settled facility cost report and corresponding charge data from the billing file. It is calculated by dividing the Medicare operating costs by Medicare covered charges.Medicare operating costs can be obtained from the Medicare cost report form CMS-2552-96, Supplemental Worksheet D-1, Part II, Line 53. Medicare covered charges can be obtained from the MAC billing file, i.e., PS&R record. For hospitals for which the MAC is unable to compute a reasonable cost-to-charge ratio, they use the appropriate urban or rural statewide average cost-to-charge ratio calculated annually by CMS and published in the Federal Register. These average ratios are used to calculate cost outlier payments for those hospitals where computed cost-to-charge ratios are not within the limits published in the Federal Register. For IRF and LTCH PPS, a combined operating and capital cost-to-charge ratio is entered here.

County code¶

The 5-digit county code where the provider is located.

Covered charges¶

This field requires the covered charges from the claim. “Covered charges” means the benefits that Medicare will reimburse on this claim.

Covered days¶

This field requires the number of covered days from the claim. “Covered days” means the number of days of inpatient stay in this facility that Medicare will reimburse on this claim.

Current census division¶

The current census division indicates the census division to which the facility belongs for payment purposes. The 9 census regions can be viewed at the U.S. Census Bureau website, here: https://www.census.gov/geographies/reference-maps/2010/geo/2010-census-regions-and-divisions-of-the-united-states.html

Date of Service¶

Enter the date of service for the visits that occurred for each revenue code, if applicable.

Device cost-to-charge ratio¶

Derived from the latest available cost report data. Does not apply to ESRD Facilities.

Diagnosis code¶

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code set used to report the beneficiary's principal diagnosis or and other diagnoses during the stay.For example, A49.02 can be entered as A4902 without decimals.

Diagnosis related group (DRG) code¶

Enter the Medicare Severity-Diagnosis Related Group (MS-DRG) for the claim. The MS-DRG is determined by the Grouper software or may be on the UB-04 claim form in FL 71.

Dollar rate¶

The dollar rates used by the Web Pricer to calculate the payment for the visits in each discipline if the claim is paid as a Low Utilization Payment Adjustment (LUPA).

Effective date¶

The effective date is the date of the provider's first PPS period, or, for subsequent PPS periods, the effective date of a change to the provider specific file. Whenever the status of any element of the file changes, the Fiscal Intermediary (FI) prepares an additional record showing the effective date. For example, when a hospital's FY beginning date changes as a result of a change in ownership or other "good cause," the FI makes an additional record showing the effective date of the change.

Electronic health record (EHR) incentive program reduction indicator¶

Enter Y or N; or leave blank.

End of life add-on day #1 amount¶

The dollar amount calculated for the first day associated with the level of care on the date of death.

End of life add-on day #2 amount¶

The dollar amount calculated for the second day associated with the level of care on the date of death.

End of life add-on day #3 amount¶

The dollar amount calculated for the third day associated with the level of care on the date of death.

End of life add-on day #4 amount¶

The dollar amount calculated for the fourth day associated with the level of care on the date of death.

End of life add-on day #5 amount¶

The dollar amount calculated for the fifth day associated with the level of care on the date of death.

End of life add-on day #6 amount¶

The dollar amount calculated for the sixth day associated with the level of care on the date of death.

End of life add-on day #7 amount¶

The dollar amount calculated for the seventh day associated with the level of care on the date of death.

End of life day units¶

This value will change depending on the End of Life days needed to estimate a claim. There are a maximum of 7 End of life days.For End of life day 1 units, enter the sum of units with revenue codes 055x (if G0299 is present) and 056x (other than 0569) on the date of death, if the date is associated with revenue code 0651, Routine home care.No units input if the lines are not associated with routine home careFor End of life days 2-7, follow the preceding format for End of life day 1 units but update for "... on the date of death minus (#) days".Example of End of life day 6 units:Enter the sum of units with revenue codes 055x (if G0299 is present) and 056x (other than 0569) on the date of death minus 6 days, if the date is associated with revenue code 0651, Routine home care.

ESRD children hospital quality indicator¶

Children's Hospitals for End Stage Renal Disease (ESRD) Facilities. Enter the code applicable to the ESRD Quality Incentive Program (QIP). - Blank = no reduction

• 1 = ½ percent payment reduction

• 2 = 1 percent payment reduction

• 3 = 1½ percent payment reduction

• 4 = 2 percent payment reduction

Estimated total pass-through amount¶

When the "HMO Paid Claim" field equals "no," this amount is the product of the total pass-through & miscellaneous field and the length of stay.When the "HMO Paid Claim" field equals "yes," this amount is the product of the sum of the total pass-through amount & miscellaneous field, subtracting the pass-through amounts for Direct Medical Education, Organ Acquisition, and Allogeneic Stem Cell Acquisition, and the length of stay.

Facility specific rate¶

The PPS Facility Specific Rate or Case Mix Adjusted Cost Per Discharge is calculated for PPS hospitals and waiver state non-excluded hospitals as the base year cost per discharge divided by the case-mix-index. New providers are entered as zero.

Federal PPS blend indicator¶

The federal PPS blend indicator variable determines the blended payment rate. The percentage payment varies by provider type.

Fiscal year begin date¶

The fiscal year begin date is the date on which the provider's cost reporting period begins. This field must be equal to or less than the effective date. This date is updated annually in the provider specific file (PSF) by the MAC to show the current year for providers receiving a blended payment based on their FY begin date.

Fiscal year end date¶

The fiscal year end date is the last day covered by the provider's cost report. The fiscal year end date is formatted as CCYYMMDD.

From date¶

Enter the date from a claim that corresponds to the Statement Covers Period “From” field of the UB-04.

HCPCS¶

Enter the Q Healthcare Common Procedure Coding System (HCPCS) code that describes the service location each revenue code, if applicable.

Health insurance PPS code¶

This field is used by the program to determine the appropriate case-mix weight for payment calculation. Enter the Health Insurance Prospective Payment System (HIPPS) code that corresponds to the earliest dated revenue code 0022 line on the claim. Medicare will only price valid HIPPS code. For a list of valid Skilled Nursing Facility HIPPS codes, refer to: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes

High routine home care (RHC) rate¶

Days 1-60 billed at the routine home care (RHC) level is paid at the high RHC rate. Claim value code 62.Days 61 and beyond billed at the RHC level is paid at the low RHC rate. Claim value code 63.Multiple RHC days are reported on a single line item on the claim. The line item date of service represents the first date at the level of care and the units represent the number of days. As a result, both high and low RHC rates may apply to a single line item.Medicare systems count 60 days from the date of admission regardless of whether some days are covered or non-covered.For a hospice patient that is discharged and readmitted to hospice services within 60 days of the discharge, the hospice days will continue to follow the patient. If the hospice patient is discharged from hospice care for more than 60 days a new election to hospice will initiate a reset of the patient’s 60-day window, paid at the RHC high rate upon the new admission.

Hospital quality indicator¶

The hospital quality indicator indicates that the hospital meets criteria to receive higher payment per MMA (Medicare Modernization Act of 2003) quality standards. If the field is blank, the hospital does not meet criteria. If the field shows "1", the hospital quality standards have been met. For more information about CMS Quality Programs, visit: https://www.qualitynet.org/

Hospital readmission reduction adjustment¶

The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions. For each eligible hospital, CMS calculates the payment adjustment factor (PAF), which represents the percent the hospital’s payment is reduced. Hospitals with higher PAFs have lower payment reductions. More information about the HRRP adjustment factor can be viewed here: https://www.qualitynet.org/inpatient/hrrp/payment

Hospital readmission reduction program participant¶

The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions. The hospital readmissions reduction program participant field indicates if an acute inpatient hospital is participating. "0" indicates that the hospital is not participating in the program. "1" indicates that the hospital is participating in the program. More information about HRRP can be viewed here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

Hospital-acquired condition (HAC) reduction program participant¶

Enter Y or N; only for those providers subject to IPPS.

Inpatient core-based statistical area (CBSA)¶

Enter the Core-Based Statistical Area (CBSA), used to wage-adjust inpatient levels of care. Hospices shall report the CBSA for inpatient levels of care in value code G8.

Inpatient core-based statistical area (CBSA) results summary¶

Core-Based Statistical Area (CBSA), used to wage-adjust inpatient levels of care. Hospices shall report the CBSA for inpatient levels of care in value code G8.

Intermediary number¶

Intermediary number refers to the fiscal intermediary (FI) or the Part A/B Medicare Administrative Contractor (MAC) to which the provider is assigned.

Intern-to-bed ratio¶

The intern-to-beds ratio is the provider's intern and resident to bed ratio. This is calculated by dividing the provider's full-time equivalent residents by the number of available beds, based on the average number of full-time equivalent residents assigned to the hospital during the fiscal year. This calculation does not include residents in anesthesiology who are employed to replace anesthetists or those assigned to PPS-excluded units. This field will display zero for non-teaching hospitals.

Lifetime reserve days¶

In this field, you may enter the lifetime reserve days for the beneficiary. Lifetime reserve days, also known as reserve days, are for when a beneficiary is in the hospital for more than 90 days.Medicare will pay for 60 additional reserve days that a beneficiary can only use once in his or her lifetime. They are not renewable once they are used.Not applicable for Indian Health Service or Contract Health Service. Lifetime reserve days are Medicare days and are only applicable for Medicare beneficiaries.

Low routine home care (RHC) rate¶

Days 1-60 billed at the routine home care (RHC) level is paid at the high RHC rate. Claim value code 62.Days 61 and beyond billed at the RHC level is paid at the low RHC rate. Claim value code 63.Multiple RHC days are reported on a single line item on the claim. The line item date of service represents the first date at the level of care and the units represent the number of days. As a result, both high and low RHC rates may apply to a single line item.Medicare systems count 60 days from the date of admission regardless of whether some days are covered or non-covered.For a hospice patient that is discharged and readmitted to hospice services within 60 days of the discharge, the hospice days will continue to follow the patient. If the hospice patient is discharged from hospice care for more than 60 days a new election to hospice will initiate a reset of the patient’s 60-day window, paid at the RHC high rate upon the new admission.

Low-volume adjustment factor¶

An adjustment received once a hospital makes a written request for low-volume hospital status and is deemed qualified to receive the low-volume payment adjustment.

LTCH DPP indicator¶

Long-Term Care Hospital (LTCH) Discharge Payment Percentage (DPP) Payment Adjustment indicates whether the LTCH is subject to the DPP payment adjustment for failure to maintain the required discharge payment percentage. A blank value indicates LTCH is not subject to the DPP payment adjustment. A 'Y' value indicated the LTCH is subject to the DPP payment adjustment.

LUGAR¶

A Lugar designation allows a hospital located in a rural county adjacent to one or more urban areas to be treated as urban for purposes of payment if it meets certain criteria. The Lugar field indicates if the MSA has been reclassified for wage index purposes. These are also known as Lugar reclassifications, and apply to ASC-approved services provided on an outpatient basis when a hospital qualifies for payment under an alternate wage index MSA. If there has not been a Lugar reclassification, this field is blank.

Medicaid ratio¶

The Medicaid ratio is used to determine if the hospital qualifies for a disproportionate share adjustment and to determine the size of the capital and operating DSH adjustments. The Medicaid ratio is the percentage of total inpatient days attributable to patients eligible for Medicaid by not Medicare Part A.

Medicare performance adjustment¶

Enter the Medicare Performance Adjustment (MPA) percentage calculated and published by the Centers for Medicare & Medicaid Services (CMS).

Model 1 bundle percent¶

The Bundled Payments for Care Improvement (BPCI) initiative was comprised of four broadly defined models of care, which linked payments for the multiple services beneficiaries received during an episode of care. In Model 1, the episode of care was defined as the inpatient stay in the acute care hospital. This field displays the discount percentage for hospitals who participated in BPCI Model 1. More information about BPCI can be viewed here: https://innovation.cms.gov/innovation-models/bundled-payments

NA day 1 add-on units¶

Enter the number of days from a prior hospice benefit period if identified by the common working file (CWF) as part of the first 60 days of Routine home care (RHC).

NA day 1 add-on units results summary¶

The number of days from a prior hospice benefit period if identified by the common working file CWF as part of the first 60 days of Routine home care.

National labor percent¶

The base payment rate is adjusted for differences in labor costs. The national labor percent indicates the percentage of the base payment amount, known as the labor-related portion, which is multiplied by a version of the hospital wage index. The result is then added to the non-labor related portion.

National non-labor percent¶

The base payment rate is adjusted for differences in labor costs. The non-labor percent indicates the percentage of the base payment amount which is not adjusted by the hospital wage index.

New hospital¶

The new hospital field will show a "Y" (Yes) for the first two years that a new hospital is in operation. It is left blank if the hospital is not within the first two years of operation.

Pass-through amount Allogeneic Stem Cell Acquisition¶

The per diem payment amount based on the interim payments to the hospital that includes acquisition amounts for allogeneic stem cell transplants.

Pass-through amount capital¶

The pass-through amount for capital is a per diem amount based on the interim payments to the hospital. Must be zero if location 185 = A, B, or C. Used for PPS hospitals prior to their cost reporting period beginning in FY 92, new hospitals during their first 2 years of operation FY 92 or later, and non-PPS hospitals or units. Zero-fill if this does not apply. Refer to the Provider Reimbursement Manual, §2405.2 for additional information.

Pass-through amount direct¶

The pass-through amount for direct medical education is a per diem amount based on the interim payments to the hospital. The field will display zero if this does not apply. See the Provider Reimbursement Manual, §2405.2 for more information: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021929

Pass-through amount for Supply Chain Costs¶

The per diem amount based on the interim payments to the hospital. Includes payment adjustments for the additional resource costs of establishing and maintaining access to buffer stocks of essential medicines. Also include payment adjustments for the additional cost for procurement of wholly domestically made NIOSH-approved surgical N95 respirators.

Pass-through amount organ¶

The pass-through amount for organ acquisition is a per diem amount based on the interim payments to the hospital. It includes standard acquisition amounts for kidney, heart, lung, pancreas, intestine, and liver transplants. It does not include acquisition costs for bone marrow transplants. The field will display zero if this does not apply. See the Provider Reimbursement Manual, §2405.2 for more information: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021929

Payment CBSA¶

Payment Core-Based Statistical Area (CBSA), a 5-digit value. Enter the appropriate code for the CBSA, 00001-89999 or 000 followed by the 2-digit numeric State code to which a hospital has been reclassified. For example, Ohio with state code 36 would be entered as '00036'. Leave blank or enter the actual location CBSA (field 35) if not reclassified.

Payment model adjustment¶

Payment Model Adjustment (PMA) Derived from payment model Technical Direction Letter.

Procedure code¶

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code set used to report the beneficiary's principal diagnosis or and other diagnoses during the stay.For example, A49.02 can be entered as A4902 without decimals.

Provider number¶

Enter between six - thirteen digit CMS Certification Number (CCN) present on the claim. For a sub-campus unit of a multicampus hospital, enter the full CCN number that includes the 6 digits main campus CCN plus the suffix. For example: 010001A. For information on CCN format, you must contact your MAC or review the Provider Specific File information found on the CMS Provider Data Service website. The National Provider Identifier (NPI) on the claim (if submitted by the hospital) is not entered in this field. You should receive both the CCN number and the NPI number on the claim. In rare circumstances, however, a hospital may only submit their NPI number without their CCN number. Should this occur, you will have to contact the billing hospital to obtain the CCN number as the Web Pricer cannot process using the NPI.

Provider PPS period¶

The Provider PPS period field is obsolete and left blank as of April 1, 1991.

Provider type¶

The provider type identifies the provider type with a two-digit code. For example: 04 is Rehabilitation facility, 50 is Rehabilitation Distinct Part, 06 is Hospital Distinct Parts. For a full list of provider types, please see the Medicare Claims Processing Manual, Chapter 3 - Inpatient Hospital Billing, Addendum A - Provider Specific File, accessible here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs

Quality incentive program (QIP) reduction indicator¶

Default value is no payment reduction, or 2% if the hospice's payments are subject to the 2% reduction for not reporting quality data.

Reclassification CBSA¶

The Core-Based Statistical Area (CBSA) code, or the rural area, to which a hospital has been reclassified for wage index purposes. If the hospital has not been reclassified, this field will be left blank or will default to display the Geographic Location CBSA.

Reduced coinsurance trailer count¶

Enter the number of APCs the provider has elected to reduce coinsurance for. The number cannot be greater than 999.

Region Indicator¶

Flag indicating if CBSA is Rural or Urban.

Report date¶

Must be numeric, enter date format here date file created/run date of the Provider report for submittal to CMS Central Office.

Sole community or Medicare¶

The sole community or Medicare field indicates if the provider is a sole community hospital (SCH) or a Medicare dependent hospital (MDH) effective with cost reporting periods that begin on or after April 1, 1990. If the provider is not a SCH or MDH, this field is blank. If the provider is a SCH or MDH, this field shows the base year for the operating hospital-specific rate, the higher of either 82 or 87. SCHs and MDHs are paid based on either the Federal rate or their hospital-specific (HSP) rate, whichever will result in the greatest payment. As of October 1, 2012, MDHs are no longer valid provider types.

Special locality indicator¶

Indicates the type of special locality provision that applies. For End Stage Renal Disease (ESRD) facilities with dates of service prior to Jan 1, 2025, value “Y” equals low volume adjustment applicable. For Dates of service on or after Jan 1, 2025, value “blank” equals no low volume adjustment applicable and value “1” or “2” equals tier number applicable for low volume adjustment.

Special payment indicator - Claim¶

The default value for this field is blank. If you know that another special payment indicator applies, you can also enter 1, 2, or 3. - 0 = default (neither condition code nor late penalty apply)

• 1 = Claim has Condition Code 66 (this means that the provider has refused cost outlier payment for this claim)

• 2 = Late filing penalty (no longer applied)

• 3 = No outlier and late penalty, combined (no longer applied)

Special payment indicator - Provider data¶

The special payment indicator code indicates the type of special payment provision that applies. A blank field indicates that the special payment is not applicable. "Y" indicates reclassified. "1" indicates special wage index indicator. "2" indicates both special wage index indicator and reclassified. "D" indicates dual reclassified.

Special provider update factor¶

The special provider update factor field is obsolete for hospitals as of Fiscal Year 1992. Effective January 1, 2018, this field is used for Home Health Agencies (HHA) only. For HHA, this fields shows the VBP adjustment factor provided by CMS for each HHA; if no factor is provided, the field will show 1.00000.

Special wage index¶

Certain providers may be assigned a special wage index. The special wage index field will display zero unless the Special Payment Indicator is set to "1" or "2."

SSI ratio¶

The supplemental security income ratio (SSI ratio) is used to determine if the hospital qualifies for a disproportionate share adjustment and to determine the size of the capital and operation DSH (Disproportionate Share Hospital) adjustments. The SSI ratio is the percentage of Medicare inpatient days attributable to patients eligible for both Medicare Part A and Supplemental Security Income (SSI).

Standardized amount CBSA¶

The Standardized amount CBSA shows the Core-Based Statistical Area (CBSA) code, or the rural area, to which a hospital has been reclassified. If the hospital has not been reclassified, this field will be left blank or default to display the Geographic Location CBSA.

Standardized amount MSA¶

The MSA (metropolitan statistical area) indicates where a provider is located. The Standardized amount MSA indicates if and how a facility has been reclassified for standardized amount. The Wage Index MSA field is formatted as a four digit code in the range 0040-9965 or, if a rural area, a two digit state code. CMS defines hospital geographic areas based on the definitions of urban areas and rural areas issued by the Office of Management and Budget (OMB). A full listing of the MSAs can be found on the OMB website: https://www.whitehouse.gov/omb/information-for-agencies/bulletins/

State code¶

The 2-digit state code where the provider is located.

Supplemental wage index¶

Enter the supplemental wage index that certain providers may be assigned by CMS. Enter zeroes if it does not apply.

Supplemental wage index indicator¶

Enter "1" for Prior Year Wage Index to be applied. Leave blank if it does not apply.

Temporary relief indicator¶

The Temporary Relief Indicator will be listed as "Y" if the provider qualifies for a payment update under the temporary relief provision. Otherwise, the field is left blank.Effective October 1, 2005, "Y" will display for IRFs located in the state and county in Table 2 of the Addendum of the August 15, 2005 Federal Register (70 FR 47880). The table can also be found at the following website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Data-Files

Termination date¶

This field provides the date on which the reporting MAC ceased servicing the provider. If there is no termination date, this field will display as zero. If the provider is terminated or transferred to another MAC, a termination date is placed in the file to reflect the last date the provider was serviced by the outgoing MAC. Likewise, if the provider identification number changes, a termination date is placed in the provider file transmitted to CMS Central Office for the old provider identification number.

Total pass-through amount and miscellaneous¶

Per diem amount based on the interim payments to the hospital. Must be at least equal to the Capital, Direct Medical Education, and Organ Acquisition pass through amounts. The following are also included in the total pass through amount: Allogeneic Stem Cell Acquisition, Supply Chain Costs, Certified Registered Nurse Anesthetists (CRNAs), which are paid as part of Miscellaneous Pass-through for rural hospitals that perform fewer than 500 surgeries per year, and Nursing and Allied Health Professional Education, when conducted by a provider in an approved program. Do not include amounts paid for Indirect Medical Education, Hemophilia Clotting Factors, or DSH adjustments. Zero-fill if this does not apply. Refer to the Provider Reimbursement Manual, §2405.2 for additional information.

Transitional corridor payments (TOPs) indicator¶

Enter the code to indicate whether Transitional Corridor Payments (TOPs) applies or not. - Y = qualifies for TOPs

• N = does not qualify for TOPs

Uncompensated care amount¶

The estimated per discharge uncompensated care payment amount calculated and published by CMS for each hospital.

Units¶

Enter the number of covered units for each revenue code, if applicable.

Value-based purchasing adjustment¶

Section 3001 of the Affordable Care Act added section 1886(o) to the Social Security Act, establishing the Hospital Value-Based Purchasing (VBP) Program. The value-based purchasing (VBP) adjustment field shows the adjustment factor.

Value-based purchasing participant¶

Section 3001 of the Affordable Care Act added section 1886(o) to the Social Security Act, establishing the Hospital Value-Based Purchasing (VBP) Program. The value-based purchasing (VBP) participant field will show "Y" (Yes) if the hospital is participating in the program and "N" (No) if the hospital is not participating.

Wage index¶

As part of the methodology for determining prospective payments to hospitals, standardized amounts must be adjusted for area differences in hospital wage levels. This adjustment factor is the wage index.Section 1886(d)(3)(E) of the Social Security Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts “for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level.” This adjustment factor is the wage index.

Wage index MSA¶

Wage Index Metropolitan Statistical Area (MSA), indicates where a provider is located as well as if and how a facility has been reclassified due to its prevailing wage rates. The Wage Index MSA field is entered as a 4-digit value, that ranges from 0040-9965. In a rural area, the Wage Index MSA is entered as '00' followed by the 2-digit numeric state code. For example, Ohio with state code 36 would be entered as '0036'.

Waiver code¶

The waiver code is set to either "Y" (Yes) or "N" (No). "Y" indicates waived, meaning the provider is not under PPS. "N" indicates not waived, meaning the provider is under PPS.

Last updated: 2026-01-30. Source: CMS Web Pricer