CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.0.0 - STU1

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.

C4BB CapabilityStatement

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.

Behavior: Search Parameters

These define the properties by which a RESTful server can be searched. They can also be used for sorting and including related resources.

Coverage_Payor

The identity of the insurer or party paying for services

ExplanationOfBenefit_Careteam

Member of the CareTeam

ExplanationOfBenefit_Coverage

The plan under which the claim was adjudicated

ExplanationOfBenefit_Identifier

The business/claim identifier of the Explanation of Benefit

ExplanationOfBenefit_Insurer

The party responsible for the claim

ExplanationOfBenefit_Patient

The reference to the patient

ExplanationOfBenefit_Provider

The reference to the provider

ExplanationOfBenefit_ServiceDate

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.period.start, for a pharmacy EOB by item.servicedDate, and for a professional and non-clinician EOB - by item.servicedPeriod.period.start.

ExplanationOfBenefit_Type

The type of the ExplanationOfBenefit

ExplanationOfBenefit_Organization

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

ExplanationOfBenefit_Practitioner

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

Structures: Abstract Profiles

These are profiles on resources or data types that describe patterns used by other profiles, but cannot be instantiated directly. I.e. instances can conform to profiles based on these abstract profiles, but do not declare conformance to the abstract profiles themselves.

C4BB Explanation Of Benefit

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

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide

C4BB Coverage

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

C4BB ExplanationOfBenefit Inpatient Institutional

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.

C4BB ExplanationOfBenefit Outpatient Institutional

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.

C4BB ExplanationOfBenefit Pharmacy

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)

C4BB ExplanationOfBenefit Professional NonClinician

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by physicians, suppliers and other non-institutional providers for professional 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.

C4BB Organization

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

C4BB Patient

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.

C4BB Practitioner

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.

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide

NUBC Patient Discharge Status 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 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

NUBC Point Of Origin

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

NUBC Present On Admission Indicator 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

NUBC Priority (Type) of Admission or Visit

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

NUBC Revenue 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 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

NUBC Type of Bill 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 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

Current Procedural Terminology (CPT) - Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes - Procedure Modifier Codes

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.

Current Procedural Terminology (CPT) - Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes - Procedure Codes

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.

C4BB Adjudication

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.

C4BB Adjudication Category Discriminator

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

C4BB Claim Identifier Type

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

C4BB Claim Inpatient Institutional Diagnosis Type

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

C4BB Claim Institutional Care Team Role

Describes functional roles of the care team members.

C4BB Claim Outpatient Institutional Diagnosis Type

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

C4BB Claim Pharmacy CareTeam Roles

Describes functional roles of the care team members

C4BB Claim Procedure Type

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

C4BB Claim Professional And Non Clinician Care Team Role

Describes functional roles of the care team members

C4BB Claim Professional And Non Clinician Diagnosis Type

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

C4BB Organization Identifier Type

Identifies the type of identifiers for organizations

C4BB Patient Identifier Type

Identifies the type of identifier payers and providers assign to patients

C4BB Payee Type

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

C4BB Payer Benefit Payment Status

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

C4BB Payer Claim Payment Status Code

Indicates whether the claim / item was paid or denied.

C4BB Payer Provider Contracting Status

Indicates that the Provider has a contract with the Payer as of the effective date of service or admission.

C4BB Practitioner Identifier Type

Identifies the type of identifiers for practitioners

C4BB Related Claim Relationship 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.

C4BB SupportingInfo Type

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

C4BB Total Category Discriminator

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

Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM)

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.

Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Coding System

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 convienence only. For authoratative information on ICD-10-CM, users should refer to the National Center for Health Statistics (NCHS) site located here.

MS-DRGs - AP-DRGs - APR-DRGs

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 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

CMS Place of Service Codes (POS)

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, version 4010, 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

NDC or Compound

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’

National Drug Code (NDC)

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
NCPDP Brand Generic Indicator

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

NCPDP Compound Code

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

NCPDP Dispense As Written (DAW)/Product Selection Code

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

NCPDP Prescription Origin Code

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

NCPDP Reject Code

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

X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes

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.

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide

NUBC Patient Discharge Status 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 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

NUBC Point Of Origin

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

NUBC Present On Admission Indicator 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

NUBC Priority (Type) of Admission or Visit

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

NUBC Revenue 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 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

NUBC Type Of Bill 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 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

C4BB Adjudication

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.

C4BB Adjudication Discriminator

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

C4BB Claim Care Team Role

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

C4BB Claim Diagnosis Type

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.

C4BB Claim Procedure Type

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

C4BB Compound Literal

CodeSystem for a Literal ‘compound’ value

C4BB Identifier Type

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

C4BB Payee Type

Indicates that a payee type may be a beneficiary.

C4BB Payer Adjudication Status

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 contracted or non-contracted for the service

C4BB Related Claim Relationship 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.

C4BB Supporting Info Type

Claim Information Category - Used as the discriminator for supportingInfo

Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes

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.

Medicare Severity Diagnosis Related Groups (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 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

CMS Place of Service Codes (POS)

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, version 4010, 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

X12 Remittance Advice Remark Codes

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.

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, including the RARC codes. 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.

NCPDP Brand Generic Indicator

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

NCPDP Compound Code

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

NCPDP Dispense As Written (DAW)/Product Selection Code

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

NCPDP Prescription Origin Code

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

NCPDP Reject Code

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

All Patient Diagnosis Related Groups (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

All Patient Refined Diagnosis Related Groups (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.

X12 Claim Adjustment Reason Codes

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.

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.

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like

Coverage1

Coverage Example1

EOBInpatient1

EOB Inpatient Example1

EOBOutpatientInstitutional1

EOB Outpatient Example1

EOBPharmacy1

EOB PHarmacy Example1

EOBProfessional1a

EOB Professional Example1

OrganizationProvider1

Provider 1

Patient1

Patient Example1

OrganizationPayer1

Payer1

Coverage Example 1

Coverage Example 1

Coverage Example 2

Coverage Example 2

EOB Inpatient Institutional - Example 1

EOB Inpatient Institutional - Example 1

EOB Outpatient Institutional - Example 1

EOB Outpatient Institutional - Example 1

EOB Professional - Example 1

EOB Professional - Example 1

Payer Organization Example 1

Payer Organization Example 1

Provider Organizaiton Example 1

Provider Organizaiton Example 1

Provider Organizaiton Example 3

Provider Organizaiton Example 3

Provider Organizaiton Example 4

Provider Organizaiton Example 4

Provider Organizaiton Example 5

Provider Organizaiton Example 5

Provider Organizaiton Example 6

Provider Organizaiton Example 6

Patient Example 1

Patient Example 1

Practitioner Example 1

Practitioner Example 1

Practitioner Example 2

Practitioner Example 2

Practitioner Example 3

Practitioner Example 3