CMS Pub. 100-04, ch. 3, § 190.17.1

Provider Specific File Data

Data Element Title

1 National Provider Identifier (not a

mandatory entry at this time)

2 Provider CMS Certification Number

(CCN)

3 Effective Date

4 Fiscal Year Begin Date

5 Report Date

6 Termination Date

7 Waiver Indicator

9 Provider Type (must be 03 or 06)

Effective July 1, 2006, 06 is no longer

valid. Contractors shall use 49.

12 Actual Geographic Reclassification-

MSA (no longer applicable effective

July 1, 2006)

17 Temporary Relief Indicator (For IPF

PPS, code Y if there is an Emergency

Department)

18 Federal PPS Blend Indicator (must be 1,

2, 3, or 4)

Data Element Title

21 Case Mix Adjusted Cost Per

Discharge/PPS Facility Specific Rate

(This is determined using the same

methodology that would be used to

determine the interim payment per

discharge under the TEFRA system if

the IPF PPS were not being

implemented.)

22 Cost of Living Adjustment (COLA)

23 Intern/Bed Ratio

25 Combined Capital and Operating Cost to

Charge Ratio

33 Special Wage Indicator (should be set to

1 if there is a change to the wage index.)

35 Actual Geographic Location

Core-Based Statistical Area (CBSA)

(required July 1, 2006)

38 Special Wage Index

48 New Hospital

63 Supplemental Wage Index

64 Supplemental Wage Index Indicator

Bill Data

National Provider Identifier Covered Charges

Provider CMS Certification

Number (CCN)

Discharge Date (or benefits exhaust date if

present)

Patient Age Other Diagnosis Codes

DRG Other Procedure Codes

Length of Stay Indicator for Occurrence Code 31, A3, B3, or

C3 to apply outlier to this bill.

Source of Admission ECT Units

Patient Status Code Claim Number

Indicator for Value Code75 to apply variable

per diem adjustment to this bill.

Outputs

In addition to returning the above bill data inputs, Pricer will return the following:

Final Payment National Non-Labor Rate

DRG/MS-DRG Adjusted Payment Federal Rate

Federal Adjusted Payment Budget Neutrality Rate

Outlier Adjusted Payment Outlier Threshold

Comorbidity Adjusted Payment Federal Per Diem Base Rate

Per Diem Adjusted Payment Standardized Factor

Facility Adjusted Payment Labor Share

Age Adjusted Payment Non-Labor Share

Rural Adjusted Payment COLA

Teaching Adjusted Payment Day of Stay Adjustment

ED Adjusted Payment Age Adjustment

ECT Adjusted Payment Comorbidity Adjustment

Return Code DRG Adjustment

MSA/CBSA Rural Adjustment

Wage Index ECT Adjustment

National Labor Rate Blend Year Calculation Version