This Section describes the expected capabilities of the C4BB Server actor which is responsible for providing responses to the queries submitted by the C4BB Requestors.

The EOB Resource is the focal Consumer-Directed Payer Data Exchange (CDPDE) Resource. Several Reference Resources are defined directly/indirectly from the EOB: Coverage, Patient, Organization (Payer ID), Practioner, and Organization (Facility).

The Coverage Reference Resource SHALL be returned with data that was effective as of the date of service of the claim; for example, the data will reflect the employer name in effect at that time. However, for other reference resources, payers MAY decide to provide either the data that was in effect as of the date of service or the current data. All reference resources within the EOB will have meta.lastUpdated flagged as must support. Payers SHALL provide the last time the data was updated or the date of creation in the payers system of record, whichever comes last. Apps will use the meta.lastUpdated values to determine if the reference resources are as of the current date or date of service.

The identity of the insurer or party paying for services

Starting Date of the service for the EOB using billablePeriod.period.start. The billable-period-start search parameter using the billablePeriod.period.start provides results with the earliest billablePeriod.start from a professional and non-clinician EOB or an oral EOB.

Member of the CareTeam

The plan under which the claim was adjudicated

The business/claim identifier of the Explanation of Benefit

The party responsible for the claim

The reference to the patient

The reference to the provider

Date of the service for the EOB. The service-date search parameter simplifies search, since a client doesn’t need to know that for inpatient and outpatient institutional EOB dates they need to search by billablePeriod, for a pharmacy EOB by item.servicedDate, for a professional and non-clinician EOB - by item.servicedPeriod and for an oral EOB – by item.servicedPeriod.

Starting Date of the service for the EOB. The service-start-date search parameter simplifies search, since a client doesn’t need to know that for inpatient and outpatient institutional EOB dates they need to search by billablePeriod.start, for a pharmacy EOB by item.servicedDate, for a professional and non-clinician EOB - by item.servicedPeriod.start and for an oral EOB – by item.servicedPeriod.start.

The type of the ExplanationOfBenefit

The identity of the organization the practitioner represents / acts on behalf of

Practitioner that is able to provide the defined services for the organization

Abstract parent profile that includes constraints that are common to the four specific ExplanationOfBenefit (EOB) profiles defined in this Implementation Guide. All EOB instances should be from one of the four concrete EOB profiles defined in this Implementation Guide: Inpatient, Outpatient, Pharmacy, and Professional/NonClinician

Data that reflect a payer’s coverage that was effective as of the date of service or the date of admission of the claim.

The profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at an institution as part of an overnight stay. The claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human Services.

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by providers of oral services including Dental, Denture and Hygiene. The ADA Dental Claim Form provides a common format for reporting dental services to a patient’s dental benefit plan.

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for outpatient services, which may include including the use of equipment and supplies, laboratory services, radiology services and other charges. Outpatient claims are submitted for services rendered at an institution that are not part of an overnight stay. The claims data is based on the institutional claim form UB-04, submission standards adopted by the Department of Health and Human Services.

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by retail pharmacies. The claims data is based on submission standards adopted by the Department of Health and Human Services defined by NCPDP (National Council for Prescription Drug Program)

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by physicians, suppliers and other non-institutional providers for professional and vision services. These services may be rendered in inpatient or outpatient, including office locations. The claims data is based on the professional claim form 1500, submission standards adopted by the Department of Health and Human Services as form CMS-1500.

This profile builds upon the US Core Organization profile. It is used to convey a payer, provider, payee or service facility organization.

This profile builds upon the US Core Patient profile. It is used to convey information about the patient who received the services described on the claim.

This profile builds upon the US Core Practitioner profile. It is used to convey information about the practitioner who provided to the patient services described on the claim.

This profile is used to convey basic demographic information about a person related to the claim.

The purpose of the CDT Code is to achieve uniformity, consistency and specificity in accurately documenting dental treatment. One use of the CDT Code is to provide for the efficient processing of dental claims, and another is to populate an Electronic Health Record.

On August 17, 2000 the CDT Code was named as a HIPAA standard code set. Any claim submitted on a HIPAA standard electronic dental claim must use dental procedure codes from the version of the CDT Code in effect on the date of service. The CDT Code is also used on paper dental claims, and the ADA’s paper claim form data content reflects the HIPAA electronic standard.

CDT is published Annually. Versions should refect the YYYY of the release.

The Council on Dental Benefit Programs (CDBP) has ADA Bylaws responsibility for CDT Code maintenance. To fulfill this obligation CDBP established its Code Maintenance Committee (CMC), a body that includes representatives from various sectors of the dental community (e.g., ADA; dental specialty organizations; third-party payers). CMC members, by their votes, determine which of the requested actions are incorporated into the CDT Code.

Please see Code Maintenance Committee (CMC) page for information about the CMC’s members and activities.

To obtain the underlying code systems, please see information here

The American Dental Association Universal Numbering System is a tooth notation system primarily used in the United States.

Teeth are numbered from the viewpoint of the dental practitioner looking into the open mouth, clockwise starting from the distalmost right maxillary teeth.

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially. There are no gaps because all used and unused codes are identified.

This code system consists of the following:

• FL 17 - Patient Discharge Status

These codes are used to convey the patient discharge status and are the property of the American Hospital Association.

To obtain the underlying code systems, please see information here

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially. There are no gaps because all used and unused codes are identified.

This code system consists of the following:

• FL 15 - Point of Origin for Admission or Visit

These codes are used to convey the patient point of origin for an admission or visit and are the property of the American Hospital Association

To obtain the underlying code systems, please see information here

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially. There are no gaps because all used and unused codes are identified.

This code system consists of the following:

• FL 67 - Present On Admission Indicator

These codes are used to report the principal diagnosis code (ICD-9 or ICD-10 code) and each of the secondary diagnoses. The 8th character in that set (first 7 are ICD) is the location used to report whether or not a condition was present on admission. The present on admission code acts as a modifier and is used to further define another code, so as to say this ICD-10 code is for a condition that was/was not present on admission. It should be noted that present on admission also appears in FL 72

To obtain the underlying code systems, please see information here

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially. There are no gaps because all used and unused codes are identified.

This code system consists of the following:

• FL 14 - Priority (Type) of Admission or Visit

These codes are used to convey the priority of an admission or visit and are the property of the American Hospital Association.

To obtain the underlying code systems, please see information here

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially. There are no gaps because all used and unused codes are identified.

This code system consists of the following:

• FL 42 - Revenue Codes

These codes are used to convey the revenue code and are the property of the American Hospital Association.

To obtain the underlying code systems, please see information here

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially. There are no gaps because all used and unused codes are identified.

This code system consists of the following:

• FL 04 - Type of Bill Facility Codes
• FL 04 - Type of Bill Frequency Codes

A code indicating the specific Type of Bill (TOB), e.g., hospital inpatient, outpatient, replacements, voids, etc. The first digit is a leading zero*. The fourth digit defines the frequency of the bill for the institutional and electronic professional claim.

Note that with the advent of UB-04, the matrix methodology of constructing the first component of TOB codes according to digit position was abandoned in favor of specifying valid discrete codes. As a result, the first three digits in TOB have no underlying meaning.

To obtain the underlying code systems, please see information here

The Value Set is a combination of two Code Systems: CPT (HCPCS I) and HCPCS II procedure code modifiers. Modifiers help further describe a procedure code without changing its definition.

The target set for this value set are the procedure code modifiers from the CPT and HCPCS files.

The Current Procedural Terminology (CPT) code set, created and maintained by the American Medical Association, is the language of medicine today and the code to its future. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT coding is also used for administrative management purposes such as claims processing and developing guidelines for medical care review. Each year, via a rigorous, evidence-based and transparent process, the independent CPT Editorial Panel revises, creates or deletes hundreds of codes in order to reflect current medical practice.

Designated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act (HIPAA) as a national coding set for physician and other health care professional services and procedures, CPT’s evidence-based codes accurately encompass the full range of health care services.

All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have common understanding across the clinical health care paradigm.

There are various types of CPT codes:

Category I: These codes have descriptors that correspond to a procedure or service. Codes range from 00100–99499 and are generally ordered into sub-categories based on procedure/service type and anatomy.

Category II: These alphanumeric tracking codes are supplemental codes used for performance measurement. Using them is optional and not required for correct coding.

Category III: These are temporary alphanumeric codes for new and developing technology, procedures and services. They were created for data collection, assessment and in some instances, payment of new services and procedures that currently don’t meet the criteria for a Category I code.

Proprietary Laboratory Analyses (PLA) codes: Recently added to the CPT code set, these codes describe proprietary clinical laboratory analyses and can be either provided by a single (solesource) laboratory or licensed or marketed to multiple providing laboratories that are cleared or approved by the Food and Drug Administration (FDA)). This category includes but is not limited to Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs), as defined under the Protecting Access to Medicare Act of 2014 (PAMA).

To obtain CPT, please see the license request form here

The Level II HCPCS codes, which are established by CMS’s Alpha-Numeric Editorial Panel, primarily represent items and supplies and non-physician services not covered by the American Medical Association’s Current Procedural Terminology-4 (CPT-4) codes; Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing. Level II alphanumeric procedure and modifier codes comprise the A to V range.

General information can be found here: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo

Releases can be found here: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets

These files contain the Level II alphanumeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage and pricing data.

The Value Set is a combination of two Code Systems: CPT (HCPCS I) and HCPCS II procedure codes. They are submitted by providers to payers to convey the specific procedure performed. Procedure Codes leverage US Core Procedure Codes composition.

The target set for this value set are the procedure codes from the CPT and HCPCS files.

The Current Procedural Terminology (CPT) code set, created and maintained by the American Medical Association, is the language of medicine today and the code to its future. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT coding is also used for administrative management purposes such as claims processing and developing guidelines for medical care review. Each year, via a rigorous, evidence-based and transparent process, the independent CPT Editorial Panel revises, creates or deletes hundreds of codes in order to reflect current medical practice.

Designated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act (HIPAA) as a national coding set for physician and other health care professional services and procedures, CPT’s evidence-based codes accurately encompass the full range of health care services.

All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have common understanding across the clinical health care paradigm.

There are various types of CPT codes:

Category I: These codes have descriptors that correspond to a procedure or service. Codes range from 00100–99499 and are generally ordered into sub-categories based on procedure/service type and anatomy.

Category II: These alphanumeric tracking codes are supplemental codes used for performance measurement. Using them is optional and not required for correct coding.

Category III: These are temporary alphanumeric codes for new and developing technology, procedures and services. They were created for data collection, assessment and in some instances, payment of new services and procedures that currently don’t meet the criteria for a Category I code.

Proprietary Laboratory Analyses (PLA) codes: Recently added to the CPT code set, these codes describe proprietary clinical laboratory analyses and can be either provided by a single (solesource) laboratory or licensed or marketed to multiple providing laboratories that are cleared or approved by the Food and Drug Administration (FDA)). This category includes but is not limited to Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs), as defined under the Protecting Access to Medicare Act of 2014 (PAMA).

To obtain CPT, please see the license request form here

The Level II HCPCS codes, which are established by CMS’s Alpha-Numeric Editorial Panel, primarily represent items and supplies and non-physician services not covered by the American Medical Association’s Current Procedural Terminology-4 (CPT-4) codes; Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing. Level II alphanumeric procedure and modifier codes comprise the A to V range.

General information can be found here: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo

Releases can be found here: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets

These files contain the Level II alphanumeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage and pricing data.

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.

Used as the discriminator for adjudication.category and item.adjudication.category for the CARIN IG for Blue Button®

Transportation Services Ambulatory Transport Reason Codes

Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber

Indicates if the inpatient institutional diagnosis is admitting, principal, other or an external cause of injury.

Describes functional roles of the care team members.

Indicates if the outpatient institutional diagnosis is principal, other, an external cause of injury or a patient reason for visit.

Describes functional roles of the care team members

Indicates if the inpatient institutional procedure (ICD-PCS) is the principal procedure or another procedure

Describes functional roles of the care team members

Indicates if the professional and non-clinician diagnosis is principal or secondary

The Value Set is a combination of three Code Systems: CPT (HCPCS I), HCPCS II procedure codes, and HIPPS rate codes. They are submitted by providers to payers to convey the specific procedure performed. Procedure Codes leverage US Core Procedure Codes composition.

The target set for this value set are the procedure codes from the CPT and HCPCS files and the rate codes from the HIPPS files.

The Current Procedural Terminology (CPT) code set, created and maintained by the American Medical Association, is the language of medicine today and the code to its future. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT coding is also used for administrative management purposes such as claims processing and developing guidelines for medical care review. Each year, via a rigorous, evidence-based and transparent process, the independent CPT Editorial Panel revises, creates or deletes hundreds of codes in order to reflect current medical practice.

Designated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act (HIPAA) as a national coding set for physician and other health care professional services and procedures, CPT’s evidence-based codes accurately encompass the full range of health care services.

All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have common understanding across the clinical health care paradigm.

There are various types of CPT codes:

Category I: These codes have descriptors that correspond to a procedure or service. Codes range from 00100–99499 and are generally ordered into sub-categories based on procedure/service type and anatomy.

Category II: These alphanumeric tracking codes are supplemental codes used for performance measurement. Using them is optional and not required for correct coding.

Category III: These are temporary alphanumeric codes for new and developing technology, procedures and services. They were created for data collection, assessment and in some instances, payment of new services and procedures that currently don’t meet the criteria for a Category I code.

Proprietary Laboratory Analyses (PLA) codes: Recently added to the CPT code set, these codes describe proprietary clinical laboratory analyses and can be either provided by a single (solesource) laboratory or licensed or marketed to multiple providing laboratories that are cleared or approved by the Food and Drug Administration (FDA)). This category includes but is not limited to Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs), as defined under the Protecting Access to Medicare Act of 2014 (PAMA).

To obtain CPT, please see the license request form here

The Level II HCPCS codes, which are established by CMS’s Alpha-Numeric Editorial Panel, primarily represent items and supplies and non-physician services not covered by the American Medical Association’s Current Procedural Terminology-4 (CPT-4) codes; Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing. Level II alphanumeric procedure and modifier codes comprise the A to V range.

General information can be found here: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo

Releases can be found here: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets

These files contain the Level II alphanumeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage and pricing data.

The Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) health insurers use to make payment determinations under several prospective payment systems. Case-mix groups are developed based on research into utilization patterns among various provider types. For the payment systems that use HIPPS codes, clinical assessment data is the basic input. A standard patient assessment instrument is interpreted by case-mix grouping software algorithms, which assign the case mix group. For payment purposes, at least one HIPPS code is defined to represent each case-mix group. These HIPPS codes are reported on claims to insurers. Institutional providers use HIPPS codes on claims in association with special revenue codes. One revenue code is defined for each prospective payment system that requires HIPPS codes. HIPPS codes are placed in data element SV202 on the electronic 837 institutional claims transaction, using an HP qualifier, or in Form Locator (FL) 44 (“HCPCS/rate”) on a paper UB-04 claims form. The associated revenue code is placed in data element SV201 or in FL 42. In certain circumstances, multiple HIPPS codes may appear on separate lines of a single claim.

HIPPS codes are alpha-numeric codes of five digits. Each code contains intelligence, with certain positions of the code indicating the case mix group itself, and other positions providing additional information. The additional information varies among HIPPS codes pertaining to different payment systems, but often provides information about the clinical assessment used to arrive at the code. Which positions of the code carry the case mix group information may also vary by payment systems.

Indicates if institutional ExplanationOfBenefit is inpatient or outpatient.

Identifies the type of identifiers for organizations

Identifies the type of identifier payers and providers assign to patients

Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient.

Indicates the in network or out of network payment status of the claim.

Indicates whether the claim / item was paid or denied.

Indicates the provider network status in relation to a patient’s coverage as of the effective date of service or admission.

Identifies the type of identifiers for practitioners

This value set includes Professional and Non Clinician Claim SubType codes.

This value set includes Professional and Non Clinician Claim Type codes.

Identifies if the current claim represents a claim that has been adjusted and was given a prior claim number or if the current claim has been adjusted; i.e., replaced by or merged to another claim number.

Used as the discriminator for the types of supporting information for the CARIN IG for Blue Button� Implementation Guide.

This value set includes FDI tooth surface codes localized for the US Realm.

Used as the discriminator for total.category for the CARIN IG for Blue Button®

Transportation Services Supporting Info Category Codes

The Value Set is a combination of values from volume 1 and volume 2 from the Code System International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and values in the Code System International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is based on the World Health Organization’s Ninth Revision, International Classification of Diseases (ICD-9). ICD-9-CM was the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States.

The ICD-9-CM consists of:

• a tabular list containing a numerical list of the disease code numbers in tabular form;
• an alphabetical index to the disease entries; and
• a classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabular list).

The National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services are the U.S. governmental agencies responsible for overseeing all changes and modifications to the ICD-9-CM.

ICD-10-CM is the replacement for ICD-9-CM, volumes 1 and 2, effective October 1, 2015.

The National Center for Health Statistics (NCHS), the Federal agency responsible for use of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) in the United States, has developed a clinical modification of the classification for morbidity purposes. The ICD-10 is used to code and classify mortality data from death certificates, having replaced ICD-9 for this purpose as of January 1, 1999.

The clinical modification represents a significant improvement over ICD-9-CM and ICD-10. Specific improvements include: the addition of information relevant to ambulatory and managed care encounters; expanded injury codes; the creation of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition; the addition of sixth and seventh characters; incorporation of common 4th and 5th digit subclassifications; laterality; and greater specificity in code assignment. The new structure will allow further expansion than was possible with ICD-9-CM.

Current and previous releases of ICD-9-CM are available here: https://www.cdc.gov/nchs/icd/icd9cm.htm

Current and previous releases of ICD-10-CM are available in PDF and XML format here: https://www.cdc.gov/nchs/icd/icd10cm.htm

Most files are provided in compressed zip format for ease in downloading. These files have been created by the National Center for Health Statistics (NCHS), under authorization by the World Health Organization. Any questions regarding typographical or other errors noted on this release may be reported to nchsicd10cm@cdc.gov.

The Value Set is a combination of values from volume 3 from the Code System International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and values in the Code System ICD-10 Procedure Coding System.

The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is based on the World Health Organization’s Ninth Revision, International Classification of Diseases (ICD-9). ICD-9-CM was the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States.

The ICD-9-CM consists of:

• a tabular list containing a numerical list of the disease code numbers in tabular form;
• an alphabetical index to the disease entries; and
• a classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabular list).

The National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services are the U.S. governmental agencies responsible for overseeing all changes and modifications to the ICD-9-CM.

The ICD-10-PCS is the replacement for ICD-9-CM, volume 3, effective October 1, 2015.

The ICD-10-PCS is a procedure classification published by the United States Centers for Medicare & Medicaid Services (CMS) (https://www.cms.gov) for classifying procedures performed in hospital inpatient health care settings.

Current and previous releases of ICD-9-CM are available here: https://www.cdc.gov/nchs/icd/icd9cm.htm

Most files are provided in compressed zip format for ease in downloading. These files have been created by the National Center for Health Statistics (NCHS), under authorization by the World Health Organization. Any questions regarding typographical or other errors noted on this release may be reported to nchsicd10cm@cdc.gov.

A link to information about the ICD-10-PCS code system - including how to obtain the content - is available at https://www.cms.gov/Medicare/Coding/ICD10.

Note: CMS is the owner of the ICD-10-PCS code system. CMS is NOT the owner of ICD-10-CM. CMS republishes the ICD-10-CM codes system on their website for convenience only. For authoritative information on ICD-10-CM, users should refer to the National Center for Health Statistics (NCHS) site located here.

This value set defines three sets of DRGs, MS-DRGs (Medicare Severity Diagnosis Related Groups), APR-DRGs (All Patient Refined Diagnosis Related Groups) and AP-DRGs (All Patient Diagnosis Related Groups). Identifying a DRG code requires a version.

MS-DRGs

Section 1886(d) of the Act specifies that the Secretary shall establish a classification system (referred to as DRGs) for inpatient discharges and adjust payments under the IPPS based on appropriate weighting factors assigned to each DRG. Therefore, under the IPPS, we[CMS] pay for inpatient hospital services on a rate per discharge basis that varies according to the DRG to which a beneficiary’s stay is assigned. The formula used to calculate payment for a specific case multiplies an individual hospital’s payment rate per case by the weight of the DRG to which the case is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG, relative to the average resources used to treat cases in all DRGs.

Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources.

Currently, cases are classified into Medicare Severity Diagnosis Related Groups (MS-DRGs) for payment under the IPPS based on the following information reported by the hospital: the principal diagnosis, up to 25 additional diagnoses, and up to 25 procedures performed during the stay. In a small number of MS-DRGs, classification is also based on the age, sex, and discharge status of the patient. Effective October 1, 2015, the diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS).

Content can be obtained on the CMS hosted page located here

APR-DRGs

3M APR DRGs have become the standard across the U.S. for classifying hospital inpatients in non-Medicare populations. As of January 2019, 27 state Medicaid programs use 3M APR DRGs to pay hospitals, as do approximately a dozen commercial payers and Medicaid managed care organizations. Over 2,400 hospitals have licensed 3M APR DRGs to verify payment and analyze their internal operations.

The 3M APR DRG methodology classifies hospital inpatients according to their reason for admission, severity of illness and risk of mortality.

Each year 3M calculates and releases a set of statistics for each 3M APR DRG based on our analysis of large national data sets. These statistics include a relative weight for each 3M APR DRG. The relative weight reflects the average hospital resource use for a patient in that 3M APR DRG relative to the average hospital resource use of all inpatients. Please note that payers and other users of the 3M APR DRG methodology are responsible for ensuring that they use relative weights that are appropriate for their particular populations. The 3M APR DRG statistics also include data for each 3M APR DRG on relative frequency, average length of stay, average charges and incidence of mortality.

3M APR DRGs can be rolled up into broader categories. The 326 base DRGs roll up into 25 major diagnostic categories (MDCs) plus a pre-MDC category. An example is MDC 04, Diseases and Disorders of the Respiratory System. As well, each 3M APR DRG is assigned to a service line that is consistent with the outpatient service lines that are defined by the 3M™ Enhanced Ambulatory Patient Groups (EAPGs).

Link to information about the code system - including how to obtain the content from 3M - is available here..

AP-DRGs

In 1987, the state of New York passed legislation instituting a DRG-based prospective payment system for all non-Medicare patients. The legislation included a requirement that the New York State Department of Health (NYDH) evaluate the applicability of the DRGs to a non-Medicare population. In particular, the legislation required that the DRGs be evaluated with respect to neonates and patients with Human Immunodeficiency Virus (HIV) infections. NYDH entered into an agreement with 3M HIS to assist with the evaluation of the need for DRG modifications as well as to make the necessary changes in the DRG definitions and software. The DRG definitions developed by NYDH and 3M HIS are referred to as the All Patient DRGs (AP DRGs).

The AP DRG code system is no longer updated as DRG classification system evolved to APR DRG. Evolution of DRG is summarized in the APR DRG methodology overview as well as in various articles.

Goldfield N. The evolution of diagnosis-related groups (DRGs): from its beginnings in case-mix and resource use theory, to its implementation for payment and now for its current utilization for quality within and outside the hospital. Qual Manage Health Care. 2010;19(1)3-16.

Averill RF, Goldfield NI, Muldoon J, Steinbeck BA, Grant TM. A closer look at All-Patient Refined DRGs. J AHIMA. 2002;73(1):46-49.

https://apps.3mhis.com/docs/Groupers/All_Patient_Refined_DRG/Methodology_overview_GRP041/grp041_aprdrg_meth_overview.pdf

Place of Service Codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes used throughout the health care industry.

This code set is required for use in the implementation guide adopted as the national standard for electronic transmission of professional health care claims under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA directed the Secretary of HHS to adopt national standards for electronic transactions. These standard transactions require all health plans and providers to use standard code sets to populate data elements in each transaction. The Transaction and Code Set Rule adopted the ASC X12N-837 Health Care Claim: Professional, volumes 1 and 2, as the standard for electronic submission of professional claims. This standard names the POS code set currently maintained by CMS as the code set to be used for describing sites of service in such claims. POS information is often needed to determine the acceptability of direct billing of Medicare, Medicaid and private insurance services provided by a given provider.

Current codes can be obtained here

Values will be the NDC Codes when the Compound Code value is 0 or 1. When the Compound Code value = 2, the value will be the literal, ‘compound’

The Drug Listing Act of 1972 requires registered drug establishments to provide the Food and Drug Administration (FDA) with a current list of all drugs manufactured, prepared, propagated, compounded, or processed by it for commercial distribution. (See Section 510 of the Federal Food, Drug, and Cosmetic Act (Act) (21 U.S.C. § 360)). Drug products are identified and reported using a unique, three-segment number, called the National Drug Code (NDC), which serves as a universal product identifier for drugs. FDA publishes the listed NDC numbers and the information submitted as part of the listing information in the NDC Directory which is updated daily.

The information submitted as part of the listing process, the NDC number, and the NDC Directory are used in the implementation and enforcement of the Act.

Users should note:

Starting June 1, 2011, only drugs for which electronic listings (SPL) have been submitted to FDA are included in the NDC Directory. Drugs for which listing information was last submitted to FDA on paper forms, prior to June 2009, are included on a separate file and will not be updated after June 2012.

Information regarding the FDA published NDC Directory can be found here

Users should note a few important items

• The NDC Directory is updated daily.
• The new NDC Directory contains ONLY information on final marketed drugs submitted to FDA in SPL electronic listing files by labelers.
• The NDC Directory does not contain all listed drugs. The new version includes the final marketed drugs which listing information were submitted electronically. It does not include animal drugs, blood products, or human drugs that are not in final marketed form, such as Active Pharmaceutical Ingredients(APIs), drugs for further processing, drugs manufactured exclusively for a private label distributor, or drugs that are marketed solely as part of a kit or combination product or inner layer of a multi-level packaged product not marketed individually. For more information about how certain kits or multi-level packaged drugs are addressed in the new NDC Directory, see the NDC Directory Package File definitions document. For the FDA Online Label Repository page and additional resources go to: FDA Online Label Repository

Denotes brand or generic drug dispensed. (NCPDP ECL 686)

Link to information about the code system - including how to obtain the content: https://standards.ncpdp.org/Access-to-Standards.aspx

Code indicating whether or not the prescription is a compound. (NCPDP ECL 406-D6)

Link to information about the code system - including how to obtain the content: https://standards.ncpdp.org/Access-to-Standards.aspx

Code indicating whether or not the prescriber’s instructions regarding generic substitution were followed. (NCPDP ECL 408-D8)

Link to information about the code system - including how to obtain the content: https://standards.ncpdp.org/Access-to-Standards.aspx

Code indicating the origin of the prescription. Indicates whether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy. (NCPDP ECL 419-DJ)

Link to information about the code system - including how to obtain the content: https://standards.ncpdp.org/Access-to-Standards.aspx

Code indicating the error encountered. Contains exception definitions for use when transaction processing cannot be completed. (NCPDP ECL 511-FB).

Link to information about the code system - including how to obtain the content: https://standards.ncpdp.org/Access-to-Standards.aspx

Oral Body Site indicating tooth numbers and area of oral cavity.

X12, chartered by the American National Standards Institute for more than 40 years, develops and maintains EDI standards and XML schemas which drive business processes globally. X12’s diverse membership includes technologists and business process experts in health care, insurance, transportation, finance, government, supply chain and other industries.

The X12 Claim Adjustment Reason Codes describe why a claim or service line was paid differently than it was billed. These codes are listed within an X12 implementation guide (TR3) and maintained by X12.

Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing.

Each RARC identifies a specific message as shown in the Remittance Advice Remark Code List. There are two types of RARCs, supplemental and informational. The majority of the RARCs are supplemental; these are generally referred to as RARCs without further distinction. Supplemental RARCs provide additional explanation for an adjustment already described by a CARC. The second type of RARC is informational; these RARCs are all prefaced with Alert: and are often referred to as Alerts. Alerts are used to convey information about remittance processing and are never related to a specific adjustment or CARC.

External code lists maintained by X12 and external code lists maintained by others and distributed by WPC on behalf of the maintainer can be found here:

https://x12.org/codes

Click on the name of any external code list to access more information about the code list, view the codes, or submit a maintenance request. These external code lists were previously published on either www.wpc-edi.com/reference or www.x12.org/codes.

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially. There are no gaps because all used and unused codes are identified.

This code system consists of the following:

• FL 67 - Present On Admission Indicator

These codes are used to report the principal diagnosis code (ICD-9 or ICD-10 code) and each of the secondary diagnoses. The 8th character in that set (first 7 are ICD) is the location used to report whether or not a condition was present on admission. The present on admission code acts as a modifier and is used to further define another code, so as to say this ICD-10 code is for a condition that was/was not present on admission. It should be noted that present on admission also appears in FL 72

To obtain the underlying code systems, please see information here

Describes the various amount fields used when payers receive and adjudicate a claim. It complements the values defined in http://terminology.hl7.org/CodeSystem/adjudication.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

Used as the discriminator for the data elements in adjudication and item.adjudication.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

Describes functional roles of the care team members. Complements http://terminology.hl7.org/CodeSystem/claimcareteamrole.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

Indicates if the institutional diagnosis is admitting, principal, secondary, other, an external cause of injury or a patient reason for visit. Complements http://terminology.hl7.org/CodeSystem/ex-diagnosistype.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

Indicates if the inpatient institutional procedure (ICD-PCS) is the principal procedure or another procedure.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

CodeSystem for a Literal ‘compound’ value.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

Identifier Type codes that extend those defined in http://terminology.hl7.org/CodeSystem/v2-0203 to define the type of identifier payers and providers assign to claims and patients.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

Indicates if institutional ExplanationOfBenefit is inpatient or outpatient.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

Indicates that a payee type may be a beneficiary.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

Describes the various status fields used when payers adjudicate a claim, such as whether the claim was adjudicated in or out of network, if the provider was in or not in network for the service.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

Identifies if the current claim represents a claim that has been adjusted and was given a prior claim number or if the current claim has been adjusted; i.e., replaced by or merged to another claim number.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

Claim Information Category - Used as the discriminator for supportingInfo.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

This value set includes FDI tooth surface codes localized for the US Realm.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version.

X12, chartered by the American National Standards Institute for more than 40 years, develops and maintains EDI standards and XML schemas which drive business processes globally. X12’s diverse membership includes technologists and business process experts in health care, insurance, transportation, finance, government, supply chain and other industries.

The X12 Ambulance Transport Reason Codes indicate the reason for ambulance transport. These codes are listed within an X12 implementation guide (TR3) and maintained by X12.

A list of codes and associated descriptions established, maintained, and published as part of an X12 Standard.

These codes are listed within an X12 implementation guide maintained by X12. All X12 work products are copyrighted. See https://x12.org/products/licensing-program for licensing terms and conditions.

Coverage Example1

Coverage Example 2

Coverage Example 3

Dental Coverage Example1

Dental Payer1

EOB Inpatient Example 1

EOB Inpatient Example 2

EOB Oral Example 1

EOB Oral Example 2

EOB Outpatient Institutional - Example 1

EOB Outpatient Institutional - Example 2

EOB Pharmacy Example1

EOB Professional - Example 1

EOB Professional - Example 2

EOB Professional - Transportation 1

Patient Example 1

Patient Example 2

Payer 1

Payer 2

Practitioner Example 1

Practitioner Example 2

Practitioner Example 3

Practitioner 4

Dental Provider 1

Provider Organization 1

Provider Organization 2

Provider Organization 3

Provider Organization 4

Provider Organization 5

Provider Organization 6

Provider Transportation Organization Example 1

Related Person 1